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HOSPITALS AND OTHER HEALTH INSTITUTIONS

Building, medical staffing, and equipment varies

greatly. The Aliabad Hospital (teaching) in Kabul, thenew Akbar Khan Ministry of Health hospital, the

Helmand Valley Authority hospital in Lashkargah, theCentral Laboratory, the new Institute of Public Health,the German-run blood-bank, conform to the higheststandards. Some of the small, local, and particularly thewomen’s hospitals are primitive. There is an active

hospital building programme. Although there are onlyabout 0-2 hospital beds per 1000 population-all acute-and most beds are free, more than half of the hospitalbeds at the time of my visit were empty. On the otherhand the outpatient departments (polyclinics) were

crowded. The reason most often given was reluctance toenter hospital, particularly by women. There are few

paediatric beds, less than 100 " neuropsychiatric " beds,and no chronic beds, the family always accepting responsi-bility for chronic or incurable patients. There is much

duplication of the hospital services and a long-term overallplan is called for.

CHIEF DISEASES

These are the communicable, the water-borne’, the

parasitic, the nutritional and other types of preventabledisease (Rogier and Kraft 1963), with tuberculosis andgastro-enteritis heading the list. With the help of W.H.O.malaria has been virtually conquered, spleen-rates in somebadly affected areas having been reduced from over 90%(Kunduz) and 50% (Kandahar) in 1952 to 0-5% in bothareas. B.C.G. campaigns and school health services existin Kabul, but they have hardly begun to touch the bulkof the population. Antismallpox vaccination is com-

pulsory, but the nomads and the women-nearly allvaccinators are male-are a problem, and there are stillmany cases. Intestinal parasite-rates are also very highand some startling nutritional deficiencies were seen.

Trachoma rates are up to 75% in some areas. Typhoidand dysentery and the high but unknown infant mortalityare primarily due to the deplorable state of the water-supplies, and to the belief that running water is, ipso facto,pure. Kabul has a pure supply from deep wells but, in theabsence of chlorination, it can hardly be considered safe.Kandahar and Mazar-i-Sharif have no piped supplies(nor of course sewerage systems) and water is obtainedfrom rivers, shallow wells, and open-water channels orjuis, used for all purposes. Notification of infectiousdiseases (from clinics and hospitals only) is admittedlyincomplete, and there is no national health legislation.A medical male ward had 2 typhoid cases with typicalfacies, dysentery, vitamin-B deficiency, anaemia ( ? due toancylostomiasis), diabetes. Cancer is " very rare " andusually superficial. Another ward had 5 convalescent

perforated typhoid cases, all of which had been treatedwith chloromycetin privately. A male surgical wardhad vesical calculus (very common), hernia, repair ofcongenital cleft lip, avulsion of external auricle by acamel, traffic injuries, 2 tuberculous osteomyelitis, burns,hydrocele.

OTHER PROBLEMS

Administration is almost entirely in the hands of doctors,who are untrained in this and in short supply. There is

great need for a better, trained infrastructure in allbranches of health administration to take over the clerical,accounting, and administrative work.

Medical students may be taught by foreign teachers inat least five other languages, in addition to Persian andPushtu. This is a serious handicap, despite the use of

interpreters. A second language as a medium of instructionshould be chosen and encouraged and, since about 80 °oof the students have already learnt English, this wouldseem to be the language of choice.The number of autopsies is negligible, even in the

medical school, and biopsies are rare. Research of anykind is conspicuous by its absence. A number of reasonswere given for this, but I concluded that the basic onewas lack of scientific curiosity. Perhaps this is due tocenturies of learning by rote, to the pressures of cut-throat private competition, or to lack of encouragement.Afghan medicine is unlikely to fulfil its task until the

saying that " a Westerner is born into a set of questions;an Afghan is born into a set of answers " is no longertrue (Dupree 1965).

CONCLUSION

It has been said that until recently Afghans attributedall their troubles to Ghengis Khan or the British. Thisattitude has now changed and any help that Britain cangive, through the Colombo Plan or otherwise, will bewelcomed. This brief account shows that it is needed.

In Kabul, the Oxus Valley, the Kandahar area, and Jalalabad, Ireceived the greatest kindness and hospitality from the AfghanMinistry of Health and medical profession, notably from Dr. RahmanHakimi, director-general of health services, who accompanied me tothe north and to Jalalabad, and from Dr. Saidi, who was attached tome throughout my stay. My thanks are also especially due to theBritish Council representative and his wife, Mr. and Mrs. A. W. C.Gibb, for many kindnesses.

BIBLIOGRAPHY

Beveridge, A. S. (1922) The Babur-nama in English. London.Dupree, L. (1965) J.R. Cent. Asian Soc. 52, 20.Mohammed Ali (1958) A New Guide to Afghanistan. Kabul.Poullada, L. B. (1962) J.R. Cent. Asian Soc. 49, 33.Rogier, J. F., Kraft, M. J. (1963) A Health Survey of Afghanistan. USAID.

(Unpublished.)Wilbur, D. N. (1962) Afghanistan. New Haven, Conn.Woodd-Walker, R. (1964) Lancet, i, 713.

Conferences

MENTAL HEALTHFROM A CORRESPONDENT

OPENING the conference of the National Associationfor Mental Health in London on Feb. 25, the Ministerof Health, Mr. KENNETH ROBINSON, said he intended todo what he could to continue acceleration in the develop-ment of mental-health services. Local-authority mental-health services were expanding faster than any othersection of their health services-150% increase in

expenditure in five years. But some local authoritieswere doing much less than others; and many schemeswritten down for building in the early years of theTen-Year Plan did not materialise in the year for which

they were planned. At this time of year there was a

rather undignified bustle to get schemes already approvedin principle by the Ministry off the drawing boards andinto the hands of building contractors before the end ofthe financial year. What we ought to have was a steadypressure throughout the year and a steady stream of

plans proceeding through to contract.THE PRICE OF MENTAL HEALTH

The evolution of psychiatric care, Prof. W. H. TRETHOWANremarked, had been long and tedious. The mental-hospitalscene had changed beyond recognition since the war, but wehad not reached the problems of mental health. Thoughresidency had decreased, readmissions were rising to an alarm-ing level. Attempted suicide, crime, vandalism, illegitimacy,alcoholic and drug addiction, death on the roads, were all goingrelentlessly up. Absence from work due to mental sickness was

546

also rising. We must spend much more on "

a really adequateprogramme of prevention ".The first difficulty was ignorance of causation, though

elsewhere in medicine many empirical prophylactic campaignshad been successful in the past. Doctors must be prepared todesert the consulting-room and do more than treat individualswho had already broken down. Professor Trethowan thought" lack of freedom of emotional expression along sociallyacceptable channels " was one of the causes of mental illness,and he quoted two examples: the caning of 21 boys for breakingbounds to see an erotic film; and a letter from a Catholic whosaid: " Catholics all over the world are now being forced tochoose between love of their wives and families or love of aseries of regulations concocted by a group of octogenariansliving in an ivory tower of their own making."

Part of the price of mental health was to spend more onmedical education, undergraduate and postgraduate. We nowknow enough-more than enough-to justify a clamour formuch more money for research, not only into the causes ofmental illness but also into the basis of mental health.

Dr. BRIAN ABEL-SMITH quoted E132 million as the sum thenation spent on mental illness-about 1/2 % of the nationalincome. The bulk went on hospitals-82 % of the mental-health budget in 1963. In the last half of the 19th century,asylum patients cost more to keep than the orphans, the aged,and the chronic sick: now they were the cheapest, and evenchronic-sick hospitals cost 40% more and acute hospitals 300%more. Hospitals for the subnormal were the cheapest of all-f:7 10. per patient per week in 1960-61. At this time childrendeprived of a normal home life were costing El 14s. per week." Future historians will regard this as very odd for a societywhich talked so much about equality of opportunity."The proportion of the health budget devoted to mental

services tended to drop slightly. From 91/,0//, on public mentalhospitals in 1938, it went to 71/2 S in 1963 (the absorption ofmost of the private sector meant that the real drop wasgreater). Almost half the total patients in hospital were, in1963, being looked after by 9% of the psychiatrists, each ofwhom had an average of nearly 300 patients. The nursingstrength (1 trained nurse to 11 patients) was the same as beforethe war, because the rise in numbers had been cancelled by theshorter hours worked. When allowances were made for changesin age structure, we spent no more of our resources on mentalillness than we did before the N.H.S. No wonder there was noeconomic return in fewer working days lost through mentaldisorder. Above all, we needed an ambitious programme ofresearch to see whether intensive-care mental hospitals at, say,E50 per bed per week were a good investment in terms of betterprognosis. " Lister and his successors have persuaded us togive the most expensive treatments to all patients, both publicand private. Freud has not."

RESEARCH: THE PRICE OF NEGLECT

A penny on the E.C. 10 would, according to Dr. J. M. TANNER,more than pay for all contemplated mental-health research. APolaris submarine would pay for all the research that had everbeen done and for the next ten years’ work. But while moneywas being squandered in the aircraft industry, we were writingsuccess stories in medicine: phenylketonuria was one, mon-golism another. The next step with mongolism was to learn todetermine when the chromosome change took place, and byaborting the factors, abolish the disorder.

Dr. D. W. WINNICOTT said that psychoanalytical researchcould not be " cramped into the pattern that suits research inthe physical sciences ". Psychoanalysts could have predicted,before the N.H.S. began, the unlimited potential hyperchondriain the community and the corresponding anxiety in the doctorthat led to overprescribing. It was also known how " the

public " might envy and hate doctors, although each memberof that public loved and trusted his own doctor. Alternativelythe public might idealise the medical profession but fail to findjust the right doctor for themselves. Public and individual

feelings concerning doctors tended to oppose each other.Discussing high-grade mental subnormality, Dr. M. W.

SussER noted an excess in the lower social classes. There werethose patients with abnormal body structure and those whowere physically and biochemically normal (perhaps three-

quarters of cases)-and it was the second group that were

predominantly linked to social class. Twin and other studiessuggested an inherited factor, but other work (e.g., on the I.Q.of American negroes) increasingly pointed towards environ-mental factors. Then the Clarkes showed how subnormals,unlike brighter people, might grow in i.Q. into their late 20s,especially those with the severest family deprivation. Dr.Susser’s own work showed that the high-grade subnormalitywithout brain damage appeared exclusively within low-classfamilies showing no middle-class affiliations, who did not sharesociety’s values of achievement through education or acquiringspecial skills. Genetic hypotheses, he thought, were ruled out;cultural deprivation was everything. The effect of schoolingcould be made more beneficial by giving a less formal education,by giving special courses in special schools (effective perhapsbecause of a higher staff ratio), by extending the years at school,and by early detection of backwardness.

SYMPTOMS OR PEOPLE?

Dr. DUNCAN MACMILLAN pointed out that old people’s pre-occupation with symptoms might lead to their unnecessaryadmission to hospital, which could in turn do irreversibledamage. The first step in treatment was for a psychiatrist andsocial worker to visit the patient to mobilise all possible com-munity resources. If these could not cope, day care, up to sevendays a week, including " long-day " care, was the next step.Emphasising the impersonality of hospital treatment, Dr.

D. H. BENNETT gave examples of the way in which personalrelationships and environment affected mental and physicalhealth. Children’s growth in matched orphanages, for example,was found to depend less on the food they ate than upon thepersonalities of the orphanage superintendents, one being happyand affectionate and the other aloof and disciplinary. Dr.Bennett called attention to the economic and human waste of

hospital treatment when no action was taken on discharge toimprove bad housing and economic conditions. " The failureto treat patients as people is costly to the patient and to society.Treating people honestly, yet kindly, accepting the scenes andrecriminations which may ensue, and being prepared to involveourselves in those secondary social issues which result fromserious and chronic illness, is part of the price which doctorsand social workers have to pay."The aim in social work was, according to Miss R. M.

MORRISON, to leave the patient a living member of his ownsocial group, although, for some, rehabilitation remained

incomplete and they needed prolonged social help. Even themost willing helpers could seldom cope with more than a coupleof lame ducks, "... so if this service is to be given to all who needit, the ordinary citizens who can offer support and acceptanceto their sick or handicapped neighbours will have to be verynumerous indeed ".

THE PRICE OF ENTHUSIASM

As Sir GEOFFREY VICKERS observed, enthusiasm was beyondprice. But the gospel preached by the enthusiast hardened intocreed and called for a different approach. Industry spent 1-2%of turnover on operational research and development. The

Ministry of Health needed to match this, for nothing was morecertain to cut the cost of ignorance and misunderstanding.Taking up the theme of operational research, Dr. G.

O’GORMAN described how his unit for autistic children had

developed. Experience showed that such children neededcontact with normal ones in order to develop relationships andto learn to communicate. He would no longer support hostels,schools, or hospitals exclusively for autistic children. The

integration of the parents into the treatment programme hadsimilarly been subject to experiment and change. Sudden

separation gave way to gradual separation within the hospital,and, in turn, to mothers caring for their children within thehospital. Dr. O’Gorman was alarmed at the possibilities ofconflict between local authority and hospital services: sharingof staff and facilities was needed all along the line.