The Face of Pathology in Afghanistan in 2006–2007

I retired from a career in neuropathology in 1997 and from forensic pathology in 2002. I wished to be of service during my retirement, a desire strengthened by my concern for personal growth. Thus, I made a number of inquiries during the next few years about the possibility of becoming a volunteer pathologist in an underdeveloped country. I was not successful and concluded that such opportunities must be rare. A laboratory is essential for the practice of pathology and I reasoned that most nongovernmental organization (NGO) hospitals were only committed to providing acute front-line medical care.

In the summer of 2006 I was visited by a long-time friend, Erika Schmidt, who had worked in Afghanistan for several years serving the needs of widows and orphans (Figure 1). She told me of an NGO hospital in Kabul and I was surprised to learn from the Web site (http://cure.org; accessed November 4, 2010) that the hospital was looking for a pathologist. By the following day I had arranged to volunteer for the 6 months from October 2006 to the end of March 2007. I later returned for the last 6 weeks of 2007.

CURE is the name of a Christian NGO in the United States that had established hospitals in 19 impoverished countries including the CURE International Hospital in Kabul, which opened in November 2005 (Figure 2). Most of the attending staff are Westerners, both long- and short-term volunteers and others on a CURE stipend. There is a strong emphasis on teaching with about 20 family practice residents as well as my 1 pathology resident (Figure 3). I was informed that there is no other such training available in the country. The quality of teaching and medical care is, in my opinion, good, possibly the best in Afghanistan, and residents (including a niece of President Karzai) appreciate this rare opportunity to learn. Although Afghan medical school teaching is conducted in the Dari language (derived from Persian), the residents have adequate skill in English, which is widely used throughout the hospital.

Volunteers and staff stayed in a series of rented houses, several kilometers from the hospital, each with 24-hour guards. I observed that such guards and walled in gardens are characteristic of Kabul, which has a long history of insecurity. We were ferried to and from the hospital by van accompanied by an armed ex-Marine who also sent us e-mail security alerts. During my second visit at the end of 2007 the security situation had deteriorated somewhat and continues to do so. Despite these factors, I rarely felt unsafe.

The pathology laboratory was set up by an American pathologist, Dr Asa Barnes, with assistance from World Wide Labs (www.wwlab.org; accessed November 4, 2008), an NGO that works to assist NGO hospital laboratories. The laboratory has fairly standard equipment including ventilated grossing station, Autotechnicon tissue processor (Olympus Corp, Center Valley, Pennsylvania), embedding center, 2 Olympus microtomes (Olympus Corp), manual staining racks and a ventilated mounting station. A top-end Olympus microscope was fitted with a digital camera (Figure 4) allowing consultation by Internet with a panel of American pathologists to which I added a Canadian, Dr Erin Ellison. Each pathologist on the panel had heard of the hospital through their interest in Christian missionary groups and volunteered their willingness to be consultants. Having left general surgical pathology for neuropathology more than 25 years ago, I was especially grateful for this facility. The histotechnologist (Figure 5) had been trained by Dr Marlene Olivera, a visiting Brazilian pathologist. Only hematoxylin-eosin and acid-fast stains were prepared on tissue sections and the appropriate stains on cytology. Other special stains and immunocytochemistry were not attempted. The hospital was unheated until December 2006 and with the temperature down to 0°C some technical difficulties were encountered. The slide on the microscope would mist up if I were not careful with my breath.

We received surgical specimens from about 60 hospitals, clinics, and doctor's offices located all over Afghanistan. About 250 specimens were processed each month including fine-needle aspirations and exfoliative cytology. Papanicolaou smears are now being added to the service although cervical carcinoma is relatively rare. We received many endoscopic biopsies of carcinoma of the esophagus. Because no radiotherapy or cancer chemotherapy was available in Afghanistan, the value of performing such biopsies was sometimes questioned by the staff.

There is no local mail service in the country, and few people have telephones. Patients or their families delivered specimens and collected reports at the laboratory (Figure 6). We had the opportunity to take gross photographs of clinical lesions, often advanced, during these visits. Patients with growing lesions may have waited months before seeing a doctor. Many outside specimens arrived with a flowery expression of appreciation for our service but with minimal clinical information. We were rarely able to obtain more, severely limiting the quality of assessment of the pathology, especially in the case of bone and soft tissue tumors.

My pathology resident, Dr Nasir Ahmad, is a graduate of the Kabul State Medical Institute (The Kabul Medical University), recognized by the Medical Council of Canada. After a year of family practice residency, in November 2005, he began training in pathology at the CURE hospital under a succession of volunteer pathologists including myself. He is very bright and highly motivated. In 2006, while on a visit to his home province of Wardak, he received death threats for working with Westerners and feared returning to his home, even for a family wedding. Late in 2007 these threats had been renewed and he felt unsafe even in Kabul. He is actively seeking a way for himself and his wife and baby son to leave Afghanistan. I entirely sympathize with him and, because of the personal relationship I have built with him, I feel that I cannot refuse to help him in any way possible. This is an obvious conflict of interest for me because my original desire was to be of some service to Afghanistan, an aim not served by his leaving the country. He could take steps to obtain an educational Canadian visa, or he might claim refugee status. If successful, he would be part of a continuing brain drain of trained and qualified people that bodes ill for the country. The future in Afghanistan is so uncertain that many physicians would choose to leave if it were possible.

Last December I was present at Dr Ahmad's graduation (Figure 7). There I met the Minister of Health Sayad Fatemi, also a physician, part of a small returning Afghan diaspora. He had returned from practice in the United States to help his struggling country.

The medical staff at CURE led me to believe that there are no pathology services for Afghans outside of Kabul. To the best of my knowledge, the CURE hospital offered the only reliable pathology service in the country. I visited a pathologist at the Afghan military hospital but his technologist was unable to produce a readable slide. A set of Leitz histotechnology equipment including tissue processor, embedding station, microtome, staining section, and mounting station had been donated a year before my visit and was still packed in cartons because no instructions or assistance to set it up had been provided with the equipment. This problem with donated equipment is well recognized, including donated pathology equipment.1 The technologist feared to damage the equipment. Since my return home, a pathologist from the American base at Bahgram, Dr Monique Hollis-Perry, is attempting to help him out while setting up a pathology service at the American Military Hospital in Bahgram.

I also visited the Kabul Medical University and was very warmly received (Figure 8). The department was poorly funded and provided only book-based teaching of medical students without teaching laboratories. I agreed to give weekly talks to the professors and began with some neuropathology, only to find the professors were much more interested in basic diagnostic surgical pathology. Thereafter I used the weekly case material from CURE to great appreciation. The medical university did have a histopathology laboratory, which was struggling to produce readable slides. In my view, the technicians were not good at problem solving, possibly the result of the educational system based on rote learning. With our advice during several months, there was improvement in the quality of slides but with inconsistent results. In my opinion, it was irresponsible for them to accept specimens for diagnosis, but, with few alternative services, some attempt at diagnosis may have been better than none. By the time of my second tour in Afghanistan the quality of their slides was improved. The professors were coming to the CURE hospital each week for instruction and consultation.

I also visited the forensic autopsy facility of the Ministry of Justice attached to the Kabul Medical University. The autopsy room was small, poorly lit, and supplied with primitive tables and instruments. No autopsies had been performed for several days because there was no heating in the building and the bodies could not be thawed. I cannot comment on the skill level of the autopsy pathologists except to say that they possessed no specific forensic training and the reports I were shown were, in my opinion, very incomplete.

Pathology is a service that is necessary as part of a sophisticated medical system. The pathology service at the Kabul CURE hospital enriches the educational experience of the clinical residents. The diagnosis of tuberculosis, leishmaniasis, and other infectious and nonmalignant diseases leads to treatment. However, in the absence of radiotherapy and chemotherapy in Afghanistan, its contribution to health care is diminished. Only a small minority of Afghans have the financial resources to travel to Pakistan or beyond for such standard treatment of malignancies. As an example, when I was at CURE, questions were raised about the value of the endoscopic biopsy of the esophagus. Carcinoma of the esophagus was the most common malignancy we diagnosed, but no treatment was available within the country. It may be hoped that the provision of an accurate diagnosis will at least benefit the family in preparing for their future.

The practice of medicine in Afghanistan is faced with shortage of both human and material resources, and pathology lags behind the development of other medical services. As long as insecurity and instability persist, progress is likely to be slow. The government health system lacks financial and material resources, and corruption is rife. At present, health directed NGOs and American military health services available to Afghans are the brightest hope of health provision. As with all other areas of civilized life, the lack of security hinders progress.

I found my time in Kabul deeply rewarding. There were hardships and frustrations, but I felt that I was in the right place at the right time for the right reasons. There are certainly individual lives that are affected for good even if the outcome for the country as a whole remains uncertain. I focused my attention on the process rather than the result, an attitude that is probably good for anyone working in Afghanistan today.