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PRT proving ingenuity is all it takes to make a difference

by Staff Sgt. Tammie Moore
AFCENT News Team

8/20/2008 - QALAT, Afghanistan (AFPN) -- In a country where the reality is that parents will have to bury one of their children before the age of 5, members of a coalition provincial reconstruction team at Zabul, Afghanistan, are working to reverse this staggering trend.

After two Air Force medical professionals spent some time on the ground in Southeastern Afghanistan, they came to a conclusion -- providing clinical medical care for locals was just a band-aid solution for three major issues plaguing the country. So they made the decision to take a step back and think outside of the box for solutions.

Capt. (Dr.) James Arnold and Capt. Tim Harrelson, physician assistant, have been hard at work looking for ways they could step beyond clinic care traditionally provided by PRT medics. The two were determined to find sustainable, cost efficient ways locals could combat the three largest medical killers in the country diarrhea, malnutrition and childbirth complications -- information they were provided by the Afghani government.

"Every environment is different; the resources are different; what you can use and what the people will accept is even different," Captain Harrelson said. "Even if you discover something that has already been done, you have to figure out how to get it accepted here. You have to be able to work with people on a human level. Those were our challenges in the beginning. We realized early that half of our job was going to be to sell the solution."

Neither of these Airmen ever anticipated they would be involved in a quest to discover feasible solutions to problems like these.

"When I was at physician assistant school I never even considered that I would do anything like this," Captain Harrelson said. When he volunteered for the deployment, the captain thought he would treat trauma cases, run sick call and deal with a few public health items, which is a more standard deployed medical mission.

"The reality of it is when you get out into your job, you have to look around in the environment to find out what the problems are and decide how you re going to fix them," said Captain Harrelson, deployed from Misawa Air Base, Japan.

The Airmen found wrapping their arms around these problems was hard.

"When we got here all we could see is what we could not do," said Doctor Arnold, deployed from Andersen Air Force Base, Guam. "We had to learn and accept what we could do and do it to the best of our ability. Once we got to that phase, we took off like a runaway train. It almost got simpler when we took a step back. You can't solve all of these children's individual medical problems, but you can tackle very simple things. That is going to impact a lot of people."

The decision was made early that they needed to create low cost and easy to replicate solutions that would be simple to implement. The primary goal they had going into the process was to provide a means for the Afghanis to be self-sufficient, not creating a cycle of dependency on coalition medical care.

Cleaning up the water
The Qalat PRT operates in the poorest region of Afghanistan, an area where most homes are made of mud without electricity and the source of running water often comes from a polluted water well or from a river where people bathe.

Doctor Arnold was determined to discover a way to provide clean drinking water to the population knowing that doing so would drastically reduce the number of diarrhea patients in hospitals. He began searching the Web for a possible solution in April where he discovered a hypochlorite generator system that would work in this environment. The system uses a probe to convert a water and salt mixture into a chlorinated solution to be bottled and taken home for families to mix into their drinking water to kill bacteria. The system cost approximately $5 a month per 300 families to maintain.

Finding a simple system that could be cheaply maintained was just the first half of the battle, however; the village elders would have to provide their blessing before it could be successfully introduced to a village. The PRT doctor met with the village elders to discuss the benefits of the system and provide them a sample, before the system was presented to a hospital in Shajoy a 45 minute drive from Qalat.

"Once we convinced them to taste it, they realized it was a good thing, and they all gave their verbal pledge, which is a big deal," the doctor said. "They all stood up and agreed that their village and their families would use it."

This approval provided the PRT the green light to take another step forward, ensuring that the hospital's electrical wiring could support the system. Doctor Arnold coordinated to have this done, but even with the proper wiring, the hospital is only able to run its power for short periods of time - a fact that will not hinder this system's operations.

The doctors delivered the system to the Shajoy hospital Aug. 9, where the team was greeted by swarms of children and inquiring looks on the adult's faces not realizing what the true impact of the troop's arrival meant. The system was delivered with almost 300 bottles to be filled with the chlorine-based solution it produces to be handed out to families.

"Everything that we are doing goes back to clean their water," said Doctor Arnold, a Des Moines University graduate. "We are really trying to get to the lowest common denominator with everything"

Sweet tastes can save lives
When it came to facing the issue of malnutrition, a local Afghani public heath administrator provided the team with a starting point. Dr. Zamarai Sultan, the Qalat public health administrator, shared some information with Doctor Arnold about a product he knew of that had been used in other countries like Africa.

Based on this starting point, Doctor Arnold and Captain Harrelson found a recipe online, in July, they thought could be successfully reproduced, and more importantly, they believed could be tweaked for the local production. The "Ready to Use Therapeutic Food" recipe they settled on called for only five ingredients - sugar, oil, powered milk, almonds and liquid vitamins, all which are available for purchase in village markets.

"We are using this particular recipe because there is no cooking required," Captain Harrelson explained. "The types of ingredients we are using are not water based, so this can stand on a shelf without refrigeration for four months. This really works perfectly. It won't go bad. It won't cause disease, and it won't cause sickness."

Doctor Arnold said he believes this, compared to other projects PRTs have done in the past, is one can have a profound effect. "We can teach them to make this; the materials are here in the country, and they can sustain this. They just need to know how to do it and know that it exists," he said.

A single batch of the sweet-tasting RUTF can feed a child who is severely malnourished for 20 days for less than five U.S. dollars. A child receives a 600 calorie serving of the supplement to eat throughout the course of a day. This routine will bring a child back to healthy state so a normal diet can be started.

The peanut butter like consistency of the supplement, designed specifically for those 6 months to 5 years old, has more benefits than just being easy to make.

"The children don't have to actually chew it, they can suck on it. They don't have to have a lot of strength or teeth," Captain Harrelson said.

The delivery team did not meet the same welcome at the Qalat hospital when they delivered samples of the RUTF supplement Aug. 10. The patients who would benefit from this product were in a room lined with 15 beds -- most with their mothers and a sibling or two at their bedside. Initially, the infants were hesitant to eat the food, but after the doctors asked the mothers to feed their children, the babies eagerly accepted it.

Doctor Sultan smiled while looking on at this development. This will help most of the babies and children here because it is a strong treatment. The babies will get healthy on it, he said.

"The doctors are jazzed," Doctor Arnold said. "They are educated; they see what we are doing for them, and they are very appreciative. One of the reasons they are so happy about this is they see us doing something, and they know they can do it too."

Captain Harrelson agreed. "It is not just something we will implement while we are here, and then we leave, it is gone. They are going to take this, and they are going to run with it. They want their kids to survive. And now they are getting the tools to do it, and realizing they can do it themselves."

Teaching others to help
The final large medical project for this PRT is helping to establish a midwife course in Qalat since one in six child births ends in the death of the mother, child or both.

A contributing factor to this problem is the culture here doesn't allow females to see male physicians, Doctor Arnold said.

This project required the least amount of research for the team since the curriculum already existed in another city. The goal is to replicate the 18-month course here, with an agreement that the graduates would remain in the local area as government employees. The class would be formed of 16 female students, all of whom had to pass a literacy test.

The hurdle facing them was gaining permission from the city council to implement the program.

Work is still in progress to form the first class for this course, which is anticipated to kick off in October.

Since most child births here occur in the home, the doctor said this class will focus on things as simple as sterilization and clearing a baby's mouth and nose, moving up to medical procedures like proper sewing and bleeding control.

"It is not unrealistic to cut the child birth mortality rate in half in an area with the implementation of this course," Doctor Arnold said.

The road ahead
For the next PRT here, these Airmen are leaving hope that they don't have to spend nine months coming up with new solutions. Instead, they can spend their time expanding these established programs throughout the province. The blue print has been made leaving a path for expansion.

"We are ready to see these programs moved on to a larger scale," Doctor Arnold said. "The Taliban works to say we are infidels. I think the people we affect with our work see that we are trying to learn their ways and see that we are trying to adapt to their way. We are trying to find ways to help them, while respecting their culture. An acceptance based on this will allow us to take big steps forward in working ourselves out of a job."

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