Mortality high in Herat’s private clinics

By Wali Mohammad Hadeed

Herat city – In November last year, Sayed Faisal and his wife visited a friend who lived in Herat city. While sipping tea, Khesraw, Faisal’s two-year-old son, suddenly had a coughing fit. The child soon turned red in the face and his breathing became ragged. Everyone present realized that Khesraw must have swallowed an almond nut, which was now lodged in his throat.

After less than half an hour, Khesraw was taken to the emergency room at the Heart district hospital. The physician in charge told Faisal that he should take his child to Herat’s Children’s Hospital as soon as possible, because the district hospital was not properly equipped to treat children.

So Khesraw was rushed to the Children’s Hospital. But the physician in charge told Faisal that his hospital didn’t have a bronchoscope, the medical instrument needed to retrieve a foreign object from the throat. The doctor suggested that the child be returned to the district hospital.

It was now 11 pm, and Faisal along with his wife and little Khesraw returned to the district hospital. A medical worker in the hospital’s emergency room sent them to the ear and throat section. But again, they were told the hospital did not have the equipment to treat the child and advised them again to go to a private hospital.

It was well past midnight when emergency room physicians at the district hospital suggested the child should immediately be taken to a hospital in India or Pakistan. Khesraw’s parents were still discussing this option when another physician entered the room and said they could take the child to Afghan-Aria hospital, which is located less than 500 meters away. He said Afghan-Aria had recently purchased a bronchoscope.

Khesraw’s parents hurried their child through the dark to Afghan-Aria hospital. The doctors told Khesraw’s father there was no option other than to perform an operation because the almond nut was lodged deep in the child’s airway. The doctors said with their new equipment they could easily retrieve the swallowed object.

Khesraw’s parents agreed to let the doctors operate, paying 8,000 afghanis (about $165). The operation was conducted with the aid of the bronchoscope. It lasted several hours, but the doctors failed to remove the almond.

Eighteen hours after he began choking, with an attending nurse standing like an interested spectator with her hands folded on her chest, Khesraw died, his parents said.

Faisal told the Institute for War and Peace Reporting he believes the surgeon’s lack of knowledge on how to use the bronchoscope led to his son’s death. Hospital director Ali Zada, however, disagrees. “My doctor is well-qualified and is not to blame for this case. We think the child started choking again after the operation and this caused his death.”

There are 50 private hospitals and clinics in Herat, and it is clear that many do not adhere to adequate medical standards, according hospital records and interviews with numerous patients and medical professionals.

This has resulted in patients leaving these medical facilities worse off than when they entered and, in an unacceptably high percentage of cases, patients dying under medical care, according to a survey conducted by IWPR that suggests a very poor performance by health care supervisors during the last 10 years.

The top official responsible for overseeing private hospitals and how they deliver services in Herat told IWPR that with only six employees working in this area, his agency is not able to adequately monitor the more than 50 private hospitals and clinics located in and around the city.

Dr Ghulam Saeed Rashed, head of the Public Health Department in Herat province, said those six employees are also responsible for recruiting staff for government agencies, controlling medicine imports at custom borders with Iran and Turkmenistan, and making determinations on which patients should be categorized as disabled. He said that if his office had enough resources to monitor private hospitals and clinics in Herat, “as many as 80 percent of them would be closed.”

“We acknowledge that the situation with the private hospitals is bad, but the public hospitals cannot accommodate all of the patients. The private hospitals do have some modern facilities. But for each new machine, they have no technicians to run the equipment.”

There are no statistics available from national or international organizations on how many people in this city die each year due to lack of oversight of medical services or the inexperience and lack of knowledge of physicians in Herat’s private hospitals.

But there are also complaints about profiteering practices among physicians. Sayed Abdullah Sadat, broadcast manager for the local private station Zindagi Radio, has made several visits to private hospitals where he says he always hears complaints from patients that physicians in these hospitals don’t care about the health of the patients.

“These physicians don’t think about anything other than money,” Sadat charges.

He says patients complaining about colds or headaches often are prescribed unnecessary laboratory tests such as X-Rays, blood work and sonograms. Sadat believes that due to the lack of oversight and control of these hospitals, physicians prescribe medicine using written codes so that the prescriptions can only be understood by the doctor and the owner of a specific drugstore.

Sadat has a personal interest in this problem. “I researched all the private hospitals looking for treatment for my son, who had also choked on a piece of food. But all the private hospitals said they could not treat him and sent us to Kabul. It was one (full) day before my child was treated.”

When the Herat doctors do agree to treat a patient, they often use advanced medical devices without having trained staff to operate them.

Dr Zaher Niazi, a pediatrician at Herat’s Shashsad Bestar Hospital, said many of these hospitals have access to modern medical devices such as bronchoscopes, endoscopes (an instrument with a long tube that is guided down the throat of the patient in order to examine visually the interior of the stomach), CAT Scans that takes pictures of the brain, and Magnetic Resonance Imaging (MRI), which are able to produce images of internal organs.

But he says there are no professional personnel in these hospitals who are capable of using these devices. “These hospitals advertise they have good facilities, good equipment and good doctors, but they don’t have any technicians to operate this equipment. Nobody,” he said.

According to documents reviewed by an IWPR reporter, doctors are blamed for contributing to deaths in as many as 30 percent of mortality cases at Heart’s private hospitals. The Forensics Office in Herat acknowledges that dozens of violations affecting patients were detected and registered during the last two years, with most of them being reported by the public.

These documents also point out the incompetence of medical doctors and medical personnel working in Herat’s private hospitals.

One of the documents recorded by the Herat Forensics Office concerns the injection of an anesthetic into a patient already diagnosed with a heart disease. According to the document, the injection led to the patient’s death. Authorities would not confirm the name of the doctor or the private hospital where he worked, saying the investigation had not yet been completed. But another Forensics Office document shows that the anesthesiologist in question was referred to the prosecution office and the primary court of Herat over his treatment of a different patient. The anesthesiologist was convicted, imprisoned and fined.

Dr Barakatulla Mohammadi, head of the Herat Forensics Office, described another violation: “This April, Nisar Ahmad, a former assistant medical doctor in the state-run hospital of Herat, was invited by Ordubagh villagers to Guzara district in Herat province to circumcise Arash, the 7-year-old son of Ghulam Nabi, and Mohammad, the 6-year-old son of Ghulam Yahya.

“Instead of Lidocaine, an anesthetic, Nisar Ahmad injected Succinylcholine, which caused the two children to become pale in the face in a matter of few minutes and then later die.”

Succinylcholine is a paralyzing agent that has been shown to cause cardiac damage in a small number of patients.

Ghulam Yahya, the father of the second child injected, told an IWPR reporter that the after the doctor injected to the first child, he asked the doctor why that child had suddenly turned pale. The doctor assured him that there was nothing to worry about and that is was just because the child had panicked upon seeing the needle.

Justice Abdulzahir Qaderi, the head of the Guzara district court who is responsible for dealing with Dr Nisar’s case, says the prosecutor, invoking Paragraph 3 of Article 400 of the penal code, has demanded a three-year prison term for Nisar. The paragraph in the penal code reads: “In the event that more than one person are killed due to an act of negligence and incaution, the perpetrator shall be convicted to an imprisonment term of no less than three years and no more than seven years.”

“If the accused had not left the scene of the crime after the death of the two children, his (potential) imprisonment term could have been less,” Qaderi said. Dr Nisar is in jail awaiting a verdict.

Dr Barakatulla Mohammadi described another case that happened in Kaisha Hospital in Herat city. Early this spring, 49-year-old Ghulam Sarvar from Nimroz province came to the hospital. Doctors were told he was having heart pains.

According to Mohammadi’s account, Kaisha doctors immediately suggested heart surgery without even looking at the patient’s electrocardiogram (EKG), which could have revealed that the patient suffered from cardiogenic shock.

Cardiogenic shock is characterized by a decreased pumping ability of the heart. Prescribing any sort of drugs, particularly an anesthetic, to a patient can prove fatal. The patient died eight hours after an anesthetic was injected into him.

Mohammadi said an autopsy revealed that the Kaisha doctors had used the wrong medicine on Ghulam Sarvar. The Forensics Office in conjunction with the District Ministry of Public Health found the hospital guilty and banned it from conducting any business for one week. Public health authorities in Herat have referred the case to the Afghan Ministry of Public Health for follow-up.

Shekib Safi, the administration officer at Kaisha Hospital, confirmed to IWPR that Ghulam Sarvar was a patient for one week. But he says Sarvar was released from Kaisha alive, and that nobody at the hospital knows the cause of death.

An IWPR investigation showed that Kaisha Hospital has not yet received a license from the Afghan Ministry of Public Health, but it has been operating for about one year.

Sayed Faisal runs a sanitary-wares shop along Blood-Bank road in Herat. He still mourns the death of his son, and every time he remembers how his child died, he says he cries and prays to God that local medical personnel acquire enough wisdom and experience.

Today, more than one year since Khesraw’s death, God has given Sayed Faisal another child, who is now three months old. Although the parents want to drown the sorrow of their first child’s death by enjoying the gift of their newly born child, Sayed Faisal says they never forget what happened to Khesraw.