Shame and simplicity in Afghanistan by ProQuest


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									                          Salon                                                                                                                                                        CMAJ

                          Shame and simplicity in Afghanistan

                                       hile working in Kabul this         workshop that left me frustrated by the
                                       past November, I had an en-        blindness educated urbanites seemed to
                                       lightening conversation            show for village politics and the futility
                          with an Afghan doctor, an intelligent           of using financial incentives to motivate
                          man who excelled in his work with in-           community health workers to do our bid-
                          ternational organizations and had re-           ding. I wanted to cry out, “How about in-
                          cently moved from a remote village to           spiring them by helping them to success-
                          Kabul. He told me about the birth of his        fully accomplish what is valued in their
                          son and how he had acquiesced to fam-           communities: bringing healthy newborns
                          ily demands and recommendations                 into the world and saving women’s
                          from international colleagues that his          lives?” They were doing it anyway.
                          expectant wife seek care from a doctor.             Simple, reality-based solutions
                              After settling into the maternity ward,     seemed to have been forgotten. Training
                          her labour stopped and did not restart by       community health workers in “hygienic”
                          nightfall. His suggestion that she remain       deliveries, for example, would be highly
                          in hospital was met with scorn: “I refuse       appropriate. It could potentially mitigate

                                                                                                                               Fred Sebastian
                          to give birth in this filthy hospital! Take     existing harmful practices and promote
                          me home!” she cried. In the privacy of          useful ones. Since 20 000 community
                          their home his mother boiled string and         health workers are already trained to pro-
                          gauze and his wife happily gave birth,          vide basic health information and serv-
                          surrounded by a loving family. I sympa-         ices, schooling them in the correct basic                             needed is large-scale implementation of
                          thized with her. Given the contrast be-         care of expectant mothers seemed logi-                                low-technology, simple solutions in ru-
                          tween Afghan homes and hospitals, I             cal. Granted, such training is a temporary                            ral areas where the majority of the pop-
                          would have done the same.                       measure in a resource-poor setting with                               ulation lives and a plan for stepwise
                              The story came after a discussion           insecurity and a destroyed health system,                             improvements to eventually achieve in-
                          about community-oriented strategies to          where maternal and neonatal mortality                                 ternational standards. Defining reality
                          address maternal and child health. I            are huge. But it is doable. Unfortunately,                            and maintaining simplicity are too often
                          lamented the vast resources invested in         it’s against a Ministry of Public Health                              forgotten prerequisites for success in
                          facility-based care when women valued           policy spearheaded in 2002 by interna-                                such a challenging environment.
                          delivering at home.1 Most funded ac-            tional organizations, which promoted
                          tivities involve training midwives and          well-intentioned goals while being seem-                              Maureen Mayhew MD MPH
                          doctors. Training uneducated village            ingly oblivious to the extreme poverty,                               Technical Consultant
                          women, who have facilitated deliveries          remarkable illiteracy rates, neophy
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