Welcome to Khost

Arrival in Khost with a full day of orientation to the hospital compound.  The death of a full-term baby puts into sharp focus the challenges that MSF faces when aprior conditions are not diagnosed or treated. 

Welcome to Khost!  I finally arrived, and had a full day of orientation to the physical layout of the hospital compound, as well as received a rich background to the history, culture and current political situation of the region, thanks to our phenomenal field coordinator (the head of everyone at this field site, essentially). 

Khost is more rural than Kabul (though the entire province is still home to over half a million people).  The climate is sunnier, warmer, there’s much more greenery around, and you can actually hear the sounds of birds chirping during the day!  On the hospital grounds, there are a climbing rose bushes, and in-between the hospital and living quarters are newly planted young saplings.

Today, a full-term baby was born with an enlarged liver and severe anemia, and ultimately died shortly after delivery.  The pediatrician had initially suspected the baby had congenital syphilis but tests on both mom & baby were negative.

During the work-up, however, the mom’s blood type was discovered to be Rhesus (Rh) factor negative. The Rh factor is a type of protein found on red blood cells; Rh negative blood does not have this protein, and is actually somewhat rare.  Rh negative pregnant women can sometimes carry an Rh positive baby if the dad has Rh positive blood, and in some circumstances, the mom's immune system will recognize the baby's blood as something foreign, and develop antibodies that attack it, potentially leading to either a stillborn baby or its death shortly after delivery.  Rhogam, easily available in developed countries, is a simple antidote given to pregnant Rh negative moms at the time of delivery that can prevent such neonatal losses in the next pregnancy.  

In this woman's case, this was her 9th pregnancy, and her 4th neonatal loss.  Turns out baby had died because mom had never received Rhogam with her prior pregnancies, and thus had developed the deadly antibodies.  Such deaths almost never occur in the US, and even if a baby started to develop signs of getting sick, we have numerous options to both monitor and treat the condition back home.  It's difficult to accept that an easily available but expensive medication could have prevented a lifetime of loss for this woman. 

Such are the challenges of healthcare here: it's not just a matter of medical resources but it's also about promoting the use of such resources and providing safe access for patients in a place where

  • 1) understanding of health issues is low
  • 2) the benefits of routine prenatal care are not widely known
  • 3) routine travel is dangerous because of the chronic political instability and frequent attacks
  • AND 4) many people can't even afford transportation to and from a clinic or hospital let alone the cost of care, most women are left to manage the perils of pregnancy (not to mention most other illnesses) alone.  

Prior to discharging this mom, the midwife talked to her about different forms of birth control considering that this was her 9th pregnancy. She had loads of questions and doubts, but after thinking it through she agreed to an IUD (intrauterine device).  We brought her to the procedure room, positioned her, and prepped her with iodine.  But as soon as she laid eyes on the metal speculum, she immediately got up from the table, put her pants back on and walked out the door. 

She was having absolutely none of it, and waved away our frantic attempts to persuade her to stay.  To be honest, if I had never seen a speculum before in my life, I probably would have had the same reaction: “You’re putting that WHERE?!  N'uh uh.  No way.  I'm outta here!”