News
Peterson makes a difference in Afghanistan
Scott Wagar
01/24/2012
For Bottineau native, Mechele Peterson, her life since graduating from Bottineau High School has been one dedicated to humanitarian work. She works in the field of pediatrics, which recently led her to Afghanistan to educate the women of th war-torn country on how to improve the care of maternal mothers and their newborn children.
After graduating from Bottineau High School in 1982, Peterson went on to earn a bachelor’s degree in paleontology at the University of North Dakota. She conducted her advanced studies in pediatrics at the University of North Dakota’s medical school, earning her medical degree in 1991.
After graduating from medical school, Peterson was employed by a variety of non-profit hospitals where she saw a variety of patients whose parents came from all walks of life. However, for Peterson, her true love was with caring for children in poverty stricken areas, and who had families found in destitute situations and struggling financially in getting proper medical care for their children.
At one point in her life, she was employed at a for-profit hospital, but soon resigned for a number of reason, one of which was the inability to see one of her patients because her fellow colleagues refused to allow her to do a consultation with the child because the parents had a minor bill of $100 at the medical facility.
With her heart set on caring for the poor and sick, Peterson accepted a position two and half years ago with Indian Health Services and was sent to Fort Defiance in Arizona to care for the children of the Navajo Indian Reservation.
“I lived just outside Window Rock, which is the capital of the Navajo Indian Reservation,” Peterson said. “The Navajo Nation is just a little bit bigger than the state of New Jersey and is in parts of Utah, Arizona, New Mexico and Colorado.”
While working for Indian Health Service in Arizona, Peterson learned that the Center for Disease Control and Indian Health Services was looking for pediatricians who would be willing to participate in a safe birthing project in Afghanistan.
“The interagency project was called Afghanistan Safe Birth Project,” Peterson said. “The goal of the project was to improve the care for women and newborns in that country. I thought it would be a great experience so I applied and was accepted.”
In November of 2010, after being on a transport flight for 24 hours, Peterson landed in Kabul, Afghanistan, to serve in the Rabia Balkhi Hospital, a medical facility that was staffed entirely by women.
“Rabia Balkhi was for women, led by women and managed by women in a male dominated society,” Peterson said. “The hospital employed a few men to do men’s work there. For example, there was no elevator in the hospital, so men were hired to carry patients up the stairs.”
Peterson stating that Afghanistan is a male dominated country is a true statement in the utmost word, and no where else is this better seen in the country than in medical facilities, because all nurses in Afghanistan are of the male gender.
“When it comes to medical facilities in Afghanistan there are some female physicians along with mid-wives,” Peterson said. “And, the majority of the female doctors were educated outside of Afghanistan. When the Taliban came into place, anybody who had enough money left Afghanistan. A lot of the young women we worked with at Rabia Balkhi, who are now doctors, grew up in Iran, India and Pakistan where they were educated after fleeing their country. When our military came into Afghanistan, they came back and began practicing medicine.”
Peterson also stated the people who remained in Afghanistan didn’t have the opportunity to advance their education, or improve in their fields through continuing education, causing mortality rates for mothers and babies to increase in the country.
The Afghanistan Safe Birth Project was established after Tommy Thompson, secretary of the United States Health and Human Services Department, toured the war-torn country and saw the appalling conditions for maternal mothers and their newborn babies.
“The project came about through the Afghan Freedom Support Act of 2002 with the United States Secretarial Initiative directing the Office of Global Health Affairs (OGHA) to improve maternal and newborn services through the Afghanistan Health Initiative,” Peterson said. “It focused on Rabia Balkhi Hospital and its catchment area in Kabul, Afghanistan.
“Operations where divided between OGHA Coordinating Team, the Center for Disease Control and Prevention Public Health Team and Indian Health Services Clinical Team, which coordinated with the USAID and Afghan Ministry of Public Health,” Peterson added. “The CDC, who primarily works in documentation, cared for the medical records, while Indian Health Services conducted the clinicals.”
Peterson stated that to understand why Thompson sent medical teams into Afghanistan, one only had to look at the death rates of the country.
“When we went into Afghanistan in 2001, it had the second highest maternal death rate in the world. The maternal death rate was 1,600 to 1,900 per 100,000 live births. If you look at the United States, the highest number is around 17. So, even in third world countries Afghanistan’s numbers were pretty astronomical,” she said. “As far as infant death rates, we were looking at around 165 deaths per 1,000 live births. When you break that down, 17 out of every 100 didn’t make it out of the hospital, which is pretty horrendous.”
Peterson also pointed out that in 2003 at the Rabia Balkhi Hospital, there were 35 deliveries a day in the medical facility; a maternal death happened every other day; there was no IV fluids in the hospital and intermittent electricity, sewage and water. There were also few surgical instruments, no textbooks, no teachers, no functional medical records, no evidence of based practices and no antenatal care.
With such alarming numbers, Indian Health Services brought together teams made up of obstetricians, mid-wives, pediatricians, anesthesiologists, nurses, pharmacists and laboratory medicines members. For the most part, individual groups would be in Afghanistan for one month before returning home and a new group would come in.
The groups’ goals consisted of strengthening the hospital’s management and leadership; develop culturally appropriate training programs for healthcare providers; improve health outcomes for mothers and newborns in line with the United Nations’ Millennium Healthcare program, which was to improve worldwide healthcare by 2020.
The group worked in a variety of departments, which gave them challenges at every step.
Education
One of the primary jobs the medical groups had was training the residents of the hospital.
Peterson stated that prior to the project starting, the residents of Rabia had a mentorship model of training where they were expected to learn through observation and questions were also discouraged. Making it worse, the residents hoarded knowledge, they didn’t teach each other, nor was there any evidence based teaching or decision making.
“The teaching was abysmal and they had no delivery experience. The two resident pediatricians under me had never been to a delivery. The first one they went to was with me. The residents did have a great ability to memorize, and they knew exactly how to do things. However, they had never done it before because in medical school they were only taught, they didn’t see patients like we do in America until they graduate from medical school,” Peterson said. “Residents also didn’t teach each other like they do in the United States where from the time individuals are students and up they are expected to participate in others’ learning processes. If you know something, you were supposed to help out your colleagues. In Afghanistan that didn’t happen.”
The clinical team used a preceptor model of teaching, which is the method of training in the U.S. This was important in caring for some of the serious illness the teams would see in Afghan, like eclampsia, a condition in pregnancy where the mother develops high blood pressure, protein spills into the urine, and fatalities can happen through a brain hemorrhage.
“In 20 years of working as a doctor I never saw one case of eclampsia, on my first day at Rabia Balkhi two women died from eclampsia,” she said. “This condition is normally cared for in the prenatal period. There was very little prenatal care in Afghanistan. So, we introduced ultrasound to them and they became proficient in treating it better because they could see where pregnant women are in their prenatal stage and what is going on during that period.”
One problem with medical residents was keeping what they learned to themselves, because they could make a profit outside of the hospital.
“There was difficulty in teaching others because they don’t earn living wages at Rabia,” Peterson said. “Residents actually had their own private clinics after hours where they can make as much money in one afternoon as they did in one month at the hospital.
“The ultra sound was just another competitive piece for them because if they could get ahead of the competition with ultra sound, then they have a leg up on their competition to make more money.”
Cesarean Sections
Cesarean section also played an important role in the education of the staff at Rabia Balkhi Hospital, which saw an alarming mortality rate.
“We discovered they were doing Cesareans on little preemies that had no chance of surviving,” Peterson said. “They were doing C-sections on babies under 1500 grams in weight, the normal weight for a C-section was 2500 grams. However, we were able to reduce the mortality rate by half through protocols and training.”
From 2002-2008, deaths in C-sections went from nine per 1,000 to four per 1,000. At the present time, the rate is one per 1,000 thanks to the hard work of the project’s staff .
Pediatrics
In pediatrics, other challenges were prominent for the clinical teams.
“There was only short term care of sick newborns; there was a need for more space; there was limited staffing of nursery; a high turnover of both physician and nursing staff and a need for a referral system,” Peterson said. “There was also a need for a dedicated nursery staff; there were no exams for the majority of newborns; a need to teach resuscitation to staff and treatment protocols for common newborn problems.”
Peterson said achievements made by the medical groups included improving the training for midwives and physicians, skin to skin contact after births for the mothers and children, establishment of system to ensure adequate equipment and supplies and developing standards of care.
One of the biggest successes in pediatrics was the American Academy of Pediatrics and United Nation Children Fund’s “Helping Babies Breath” pictograph.
“The program helped resuscitate babies in a simple way with little resources, which means you don’t need any high tech equipment, you only need a bag mask and a towel to dry the baby,” Peterson said. “The diagram is color coded and was intended for people who cannot read, non-medical trained people and for the number of different languages that are spoken in Afghanistan. It simply showed people what to do through pictures.”
In other areas of birthing in the hospital, Peterson stated that anesthesia was improved through the education of spinal anesthesia and protocols; completely overhauling the lab system; the development of microbiology abilities and improving blood bank procedures; along with acquiring warehouse managers for the pharmacy department and providing better quality medicine.
Midwives
Peterson stated that the training of midwives was Indian Health Services most positive venture while in Afghanistan.
“There has been professional midwify education in Afghanistan since 1960s. However, when the Taliban came in the women in this profession had to go underground or go out of the country, which meant they didn’t have updates in training for many years,” she said. “In 2002, there were only 468 midwives in the country. At last count there were 2,700 of them, but the country needs at least 11,000 midwives.”
Peterson added that when the clinical teams came into Afghanistan they offered refresher courses and gave formal training to midwives. Rabia Balkhi Hospital also established the Afghan Midwives Association, which has produced its own training and continuing education, and is working toward registration, licensure and competency assurance.
“The midwives portion of the program has been very successful and sustainable and we consider it one of our greatest successes,” Peterson said.
Medical Records
As for medical records in the hospital, Peterson said they really didn’t exist when the program started.
“When we got there, there was no real medical record system. Patient’s vitals were written on their arms and there was a sheet of paper with a couple of orders on it.” Peterson said. “The records they had were not stored by the patient’s name like we do in America. They stored them by day of discharge. The records were also just a bundle of paper, which was stapled together by old hypodermic needles which they clipped together. Each bundle was then tied together by used, recycled gauze and they (the bundles) were just thrown together. So, it was icky to say the least.
“One of the reasons for poor medical records in Afghanistan is that the people keep to the oral tradition, mainly due to variable illiteracy rates in the country,” Peterson added. “It is also a culture of blame. If a person writes something down, and something happens, they receive blame for it if it is their fault or not, which in turn the person can be punished badly for it. So, they don’t want to write things down. However, we pushed for written documents because writing on charts does make a person accountable and we wanted them to be accountable.”
The CDC, because of its dealings in documentation, cared for the medical records in the birth program by starting the hospital out on log books. Today, the medical records department in Rabia Balkhi is organized by the patients’ names through electronic files and stored in an orderly fashion through stakes.
Security Threats
In the month that Peterson was in Afghanistan, she was stationed at the American Embassy in Kabul. With the dangers in the war-torn city, the medical staff wasn’t allowed to leave the embassy ground with the exceptions of their daily trips into the city’s hospital.
During the daily trips to Rabia, the staff was granted a military escort to the medical facility in heavily armored vehicles to protect them from gunmen, road side bombs and other type of attacks.
“Things were safe for us while we were in the Green Zone, but once outside the Green Zone our drivers took us to the hospitals at different times of the day and through different routes of the city for our protection,” Peterson said. “However, once inside the hospital, our guards left us and there was no protection within the hospital. Oddly, in the 10 years that the clinical groups have been at the hospital, every building on the block has been targeted but the hospital. In fact, I didn’t hear one gun shot while I was in Afghanistan, but shortly after I left, the shooting that happened at the airport, which made national news, took place.”
As for Peterson and her thinking, she is no missionary or hero when it comes to her trip to Afghanistan. Instead, her heroes are the women who work daily in the women’s hospital.
“The women who left the country when the Taliban came, were educated, and then came back are very brave women. By coming come back with an education, it could have meant punishment by law, and yet, they came back to help, which takes courage and strength, and they definitely had that,” Peterson said. “Not only did they face punishment, but each day they had to receive permission from their father or husband to get an education or even to come to work. If a father or husband on any given day said they couldn’t go, they couldn’t go. And yet, these women have fought through that. To be that strong and happy each day considering where they are at, this shows me that they are amazing women.
Peterson is supposed to go back to Kabul next month, but in recent weeks the U.S. government stopped the funding for the project, eliminating the project.
“Seeing the project cease was difficult for me because it is one of the most sufficient projects which have been funded,” she said. “And, by 2014, it was to be completely self-sufficient. So, it is sad to see it end this way.”
For Peterson, her trip to Afghanistan was a true blessing to her.
“To go somewhere that is so desolated was a gift to me. To be among people who have absolutely nothing, but continue to move forward was a great insight to me. The smallest thing to them is so important and it made me feel like I was doing something right by being there and helping the best I could,” she said. “It was a humanitarian mission to me that allowed me to connect through a huge cultural barrier. I feel like I accomplished something helping others who have so little. It was a humbling experience.”