Abstract
There are several challenges that face medics in remote locations. Some are attributed to the environment, while some are attributed to other factors like infrastructure, security concerns, hygiene and cultural diversity of residents in these remote locations. This report aims at advising the management on the factors that should be considered when deploying medical staff to Kabul, Afghanistan. It further analyzes pre-deployment situation, facilities, equipment, supply and re-supply, health risk assessment, protocols, guidelines and communication procedures, and finally emergency response planning. The paper also gives recommendations on all the issues analyzed.
Introduction
Afghanistan is a country that has faced frequent war situations, especially since the late 1970s, after opposition forces opposed its social policy. According to Coppola (2000), the opposition forces are commonly called mujahidin are viewed by many countries as terrorist groups, and have been attacked by the United States over their terrorist activities. To date, the country is politically unstable and several terrorist attacks, normally targeted at foreigners, take place regularly. It is therefore essential that the management takes care of the security needs, among other needs, before deploying medical staff to such remote and dangerous places. Below is a report that the management should take into consideration, when deploying medical staff to Kabul, Afghanistan.
Pre-deployment and recommendations.
Before the deployment of the medic to remote locations, it is very important to carry out pre-deployment preparation. This operation is done to ensure that the personnel have lower chances of experiencing health and medical problems. It is also done in order to have prior knowledge of health and medical problems that face the staff, so that the medic can be prepared for any eventuality. The programs can be changed to suit the prevailing circumstances and project, so that they cater for all the needs of the organization.
The benefits of a pre-deployment program include; reducing emergencies that occur in the field, reducing compensation claims by the workers, reducing litigation, and increasing the morale of the employees. This enhances the well being of the employee and subsequently leads to increase of productivity by the employees. The overall goal of pre-deployment program is to help employees adapt to the unfamiliar conditions that are present in the field, through anticipating future situations and ways of dealing with them beforehand.
The ability to adapt to situations is influenced by several factors that include; differences between the culture, religion, social systems, language, physical amenities, hygiene and health condition of the medics and employees, with regards to the remote areas. In Kabul, Afghanistan, the culture is mostly oriented towards the Muslim faith. This requires the management to train the staff on the overall practices expected of them, so that they adapt to the Afghan way of life, and do not offend members of the Muslim faith, by for example eating pork, which goes against their faith.
According to Soreide & Grande (2001), there are other factors that should be considered, in addition to the above factors, and these are called ‘home’ factors. These factors come into play when the employees are stay for long periods without leave, or when they are deployed to conditions that are hazardous. Such factors include stability of employees’ relationships or marriage, will and legal arrangements, financial positions of dependents, and communication with them, taxation and other factors. The management should make sure that adequate measures are in place, to take care of the above factors, so that the employees are motivated to work.
The management should screen the employees before deploying them, so that any underlying medical conditions that they possess, may be identified and dealt with. Since it is often common for the medics to be deployed, regardless of the underlying conditions, screening will help the management make provisions for any eventuality, relating to the medical conditions. In case a condition is identified, and it can be treated before the deployment, treatment takes place. Some of these conditions may include minor surgeries, dental treatment, optometry, vaccinations among others. The medical screening should involve laboratory tests and chest x-rays, and copies of records given to medics at the field site.
Facilities, equipment, supply, re-supply and recommendations.
There are different physical structures that are present in a remote medical site, such as Afghanistan. Medical equipment and supplies also vary, amongst different environments, and it is therefore prudent to understand different requirements, that influences management. There are basically two categories of facilities; static and mobile facilities. Static facilities exist at the physical location such as clinic or hospital. These facilities may also be improvised, such as storage rooms, houses and even hotels. Mobile facilities, on the other hand, are generally movable, though at times may require heavy equipment to move them. A simple form of health or medical facility is the first aid kit, while more complex ones include towed trailers, dedicated vehicles, pre-fabricate and pallet-borne units.
Each facility should be designed to serve all functions that were envisioned by planners of the project. The management should ensure that the facilities are be well equipped to serve the same needs. The facilities should ideally contain a containerized clinic, a waiting area for patients, and quarters where the medics live. The facility should be constructed in such a way that there is room for expansion, for example, the possibility that a specialized module may be converted to a modular complex. An illustration would be the conversion of an aid station, in Kabul, to a primary care clinic that houses patient wards, dental unit, intensive care unit, x-ray room, laboratories and others.
The management should ensure that the best quality of equipment is available, and in sufficient quantities, regardless of the equipment prices, in order to ensure that the required needs are met. It is also important to ensure the right amounts of equipment is available, since there is usually a time lag between ordering and receipt of the same, especially due to the fact that Afghanistan is remote. The management should also ensure that the equipment purchased, is compatible with the available power in the sites. When operating battery powered equipment, such as laryngoscopes, the management should ensure that there are adequate batteries available. If not, the management should ensure that the batteries can be readily purchased in local Afghan markets. Rechargeable batteries are also good alternatives, in such circumstances.
According to Bleaney ; Vogelsang (2006), there is need for the management to ensure that the equipment is regularly maintained, to make sure that it works at the optimum level. This should involve availability of spare parts that can be used in case there is malfunction, or if the equipment breaks down. They further add that, it is prudent for the management to guard its property against theft, since that is a real possibility in Kabul. This is characterized by the many terrorist groups present, that would grab anything valuable to finance their activities. The management should go further and involve mark the equipment, record serial numbers and model names, secure the facility, and also place tracking devices on the expensive equipment. There should be round the clock security to discourage theft of the equipment.
When dealing with supplies, the management should ensure that there are sufficient quantities present, that can last for the period until re-supply. This is because ordering for new supplies in Kabul takes significant amount of time, due to the limited infrastructure present. The management should also ensure that the supplies available, are genuine, and have the potential to deal with the purpose they are intended for. This is especially important for third world countries, like Afghanistan, where local drugs have limited potency, and some are imitations, that do not work as effectively as they are supposed to. The management should also provide proper storage facilities, to guard against contamination and damage to the supplies. Such occurs due to exposure excessive heat, which is common in Kabul, presence of moisture, as well as exposure to certain insects and organisms.
Re-supply takes long for countries like Afghanistan, where medical camps are in remote places, and there is delay in the transport of drugs and other supplies. This is especially common in Kabul due to the rough terrain, limited infrastructure, and the general insecurity that prevails over the country as a whole. Other factors such as ordering policies and system, transport by ship and aircraft, and importation policies, should be carefully considered when ordering for supplies, since they also affect the duration in which supplies arrive. Further activities that the management should undertake is keeping of accurate supply records that take into account, the maximum time taken to acquire new supplies.
Protocols, guidelines, communication and recommendations.
Health care and medical services require guidelines and protocols. Guidelines are brought about by research, which provides guidance in diagnosing and treatment of the conditions and diseases. Protocols are similar to guidelines, but are more strict in application, and mostly apply to emergency medical staff, that is technicians and nurses. Both work to reduce the risks faced by patients, as well as enhancing quality of health care for patients. They also serve the as legal basis for execution of skills by clinicians. It is the duty of the management to ensure that there is strict adherence of guidelines and protocol, in order to give the highest quality of health care to patients, as well as reduce instances of liability, arising from cases of malpractice.
In terms of communication, it is very important that there are clear lines of communication between the home office and the remote site in Kabul. This will enable instructions to be received and acted upon, in good time. In a remote place like Kabul, communication is easily affected by satellite and radio systems. There is also the possibility that a radio operator handles the radio calls, and thus there is room for breakdown in communication between the medics, the operator and the home office. The management should take measures to prevent such, for instance, through using an operator conversant with the medical practices and terms, so that he or she is able to detect any inconsistencies in information provided.
According to Vogelsang (2004), the management should also be aware of the time lag, in implementation of instructions that may occur, due to difference of location of the radio and the actual clinic. This should be corrected by, for instance, placing the radio near the clinic, or having an efficient system of communication, between the clinic and the radio operator. The management should have a communication plan that would include frequencies used, contact names, message forms, speech protocols, communication procedures, emergency procedures among others. This plan would ensure that there is effective communication between the medics in Afghanistan, and the home office.
Emergency response planning and recommendations.
Disasters and emergencies develop quickly, leaving very little time for effective response. It is very important to have prior plans for emergencies, so that when they happen, the employees might know the next course of action. It is also important for the management to predict and put in place appropriate counter measures, since most emergencies occur after long periods,of presence of predisposing factors. This means that signs of disasters waiting to happen can be detected, and appropriate training of employees on how to counter the emergency, will lead to reduction of impact of emergencies, if they do happen. This is due to minimization of panic, since everyone will have an idea of the appropriate plan of action.
For instance, in Afghanistan, there is limited water supply infrastructure. This means that there is a possibility of water poisoning, if poisonous substance comes into contact with broken water pipes. The management should take appropriate counter measures, such as maintenance of water system infrastructure and regular water inspections. Another risk that is expected, is either the attack of the medical camp by terrorists, or the kidnapping of foreign medics by Afghan terrorist groups. This is an expected risk since it has happened a lot of times in the past. The management should take counter measures, such as guarding the facility, as well as having a stand-by response team that will act against any act of aggression.
The management should have a clear response plan that is in concise terms. The plan should state the chain of command with clear titles, names and responsibility of each person. The decision makers should be based both off and on the site. The importance of direct leadership in times of emergencies is important, since absence of leadership will lead to panic and escalation of the situation, further injuries and destruction of property. There should also be a disaster response team, and risk assessors. The disaster response instructions should describe all relevant processes, escape procedures and assembling points. This is very important in case of an attack on the facility by Afghan terrorist groups.
The determination of perceived and actual risks, should involve analysis of historical occurrences such as floods, earthquakes and other significant events. In Afghanistan, there is a real threat of violence and suicide bombings, and the management should ensure that there is an emergency plan that takes these factors into consideration. After the management has identified the risks and hazards that face its staff and operations, appropriate responses are formulated, depending on the resources and personnel available. The general response team should be able to handle emergency medical support, fire suppression, search and rescue, initiating emergency procedures, security and safety, terrorist attacks amongst other situations. An evacuation facility may be required, such as survival craft, life raft, a vehicle convoy amongst others.
In cases where the patient needs specialized care, there may be need for a medical or casualty evacuation. This may take the form of a vehicle, water craft, air craft, animal or human borne means. Such means should be carefully evaluated since there are challenges, associated with them. These include; the effect of altitude on equipment and patient when using air crafts, the availability of equipment’s power supply when transporting patients, protecting the patient from harsh climatic conditions such as rain and heat, toilet facilities when traveling for long durations, and general security for the employees and patients when traveling throughout Afghanistan. This may necessitate the provision of escort service in such situations.
Health risk assessment and recommendations
This involves identifying quality and quantity of hazards to human health. This is done through identification of the hazard, its quantification, determining exposure and characterizing the hazard. This applies the general risk management principles, and removes, or minimizes the hazard, thus reducing the risk exposure. Such risks may emanate from harsh geographical and climatic conditions faced in remote locations. These may involve excess heat and cold, rain, wind, and other environmental factors.
Provision of health and medical care is challenging, especially in remote places like Kabul. This is due to factors like restricted work place, lack of supplies and breakdown in communication. There is also limited reference material from libraries, in such environments. The management should ensure that the medics have adequate reference material, for use in their line of work. This can be achieved using sources specifically designed for remote locations like Afghanistan. These include Blue Trunk Library, by the World Health Organization, or other Internet sources.
When living in the field, there may be harsh environmental, social and cultural changes that affect the workforce. Such may include new cultures, foods, hygiene, sanitation and water needs. It is important for the management to train workers on how to maintain high standards of cleanliness within the working environment, so that there is no outbreak of diseases. Such practices should include washing hands before and after eating, washing hair and body, cleaning the working area, changing bed linens when patients have recovered, cooking and food hygiene among others. Others include sterilizing equipment, using of protective clothing, and properly disposing the medical waste.
In terms of sanitation, the management should provide proper mechanisms of disposing waste, both human and medical. These mechanisms may include latrines, sewage treatment systems, use of septic tanks, amongst others. Sanitation should also include preparation of food under high standards of cleanliness, and controlling pollution of the environment. Food should be handled, prepared, served and stored under hygienic conditions, and the right temperatures to avoid contamination. When dealing with water, the management should advise employees on the right intake of water to consume, per day in order to meet their health needs. The work force should be however careful when dealing with portable water sources, such as streams and rivers, since the water might be contaminated.
In places such as Afghanistan, the possibility of water poisoning is very real, since some Afghans perceive all foreigners to be enemies, and plan to use all means to kick them out. This means that appropriate counter measures should betaken to guard against these forms of sabotage. This involves frequent testing of the water, and regular disinfecting, in order to detect any contamination early. It also involves securing the source of water and guarding it appropriately. Treatment should involve using ultra violet rays, chemicals, boiling, filtration amongst other forms of treatment.
Conclusion and recommendations.
It is clear that working in Afghanistan has potential risks that need to be neutralized. These are due to the harsh climatic and environmental conditions, limited infrastructure and the threat that foreigners face, in Kabul. It is the responsibility of the management to adequately plan all aspects of working in remote environments, so as to safeguard the lives of the employees and patients. The management needs to plan for relevant equipment and supplies, to reach the medics and staff in Kabul, on time. Factors such as time lag between ordering and receiving supplies, should be carefully assessed when planning for delivery of supplies.
The management should also ensure that the staff has the right attitude when going to Afghanistan, so that they may blend in with the local culture, and are not offensive to local practices. This involves training on expected forms of behavior, and how to cultivate relationships with Afghans. The other factor that the management should consider before deploying its staff, is the security situation in Afghanistan. There is a common trend in Afghanistan where foreigners are kidnapped by terrorists, in exchange for ransom. The management should ensure that proper security is in place, and in addition to that, it should anticipate all potential threats to its staff and operations, and formulate plans of neutralizing them. This should involve guarding its facility, formulating an exit plan, guarding the source of water, among other factors. Finally, the management should ensure proper sanitation and hygiene is upheld at all times, so as to prevent contamination and spread of diseases.
References.
Bleaney, C. H., Vogelsang, W. (2006). Afghanistan: A Bibliography. Atlanta: BRILL.
Coppola, D. P. (2000). Introduction to International Disaster Management. Washington:
Butterworth-Heinemann.
Gawande, A. (2004). Causes of war-Military care for the wounded from Iraq and Afghanistan. New England Journal of Medicine. Retrieved on October 20, 2008 from <content.nejm.org>.
Soreide, E., Grande, C. M. (2001). Prehospital Trauma Care. New York: Informal Health Care.
