An Afghani Surgical Oncologist Discusses the Challenges of Delivering Cancer Care in a War-Torn Nation

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In this installment of The ASCO Post’s Global Oncology series, Guest Editor Chandrakanth Are, MBBS, MBA, FRCS, FACS, spoke with Ahmad Bashir Barekzai, MD, Consultant Surgical Oncologist at Ali Abad Teaching Hospital, Kabul, Afghanistan. Built in 1931, under the direction of Afghanistan’s king Muhammad Nadir Shah, the Ali Abad Hospital is the nation’s oldest hospital, originally created to address the tuberculosis epidemic that ravaged the country. Although it was severely damaged during the civil war that tore Kabul apart in the 1990s, Ali Abad Hospital was restored and is currently a 250-bed teaching hospital.

Ahmad Bashir Barekzai, MD

Ahmad Bashir Barekzai, MD

A Family Reshaped by a Sniper’s Bullet

In 1979, the then Soviet Union invaded Afghanistan, precipitating a bloody, 10-year war during which upward of 2 million Afghanis died. “I was 3 years old when the Soviets invaded our country,” remembered Dr. Barekzai. “Our family lived in a small village outside the capital city of Kabul. My parents, my brother, and I shared a house with my grandparents, uncles, aunts, and cousins, so it was a large family setting. Things were difficult during the war, especially for the educated class, who came under suspicion by the rebels.” 

Dr. Barekzai continued: “When I was young, maybe just 5, we moved to Kabul, into the city. It was then that my sister was born, and our family became five. When I was in 7th grade, the mujahideen [those engaged in jihad] came to Afghanistan to fight against the Soviets. That’s when the war really spread all over the country, and the fighting was fierce. There was a point when a cease-fire occurred, but it was short-lived; during that period, perhaps because we let our guard down and went outside to play while at school, my younger brother, who was in 4th grade, was shot in the neck and killed. I don’t know where the bullet came from, but it took his life. And that was when the war exploded again, all over the country. My father was an engineer, and he and my mother were government employees. With the fighting, we moved out of Kabul, traveling to other provinces, even into Pakistan, where we lived in immigrant camps. However, when the war slowed down, we moved back to Kabul, as my parents needed to work for the government and support the family.”

Educational Challenges

Dr. Barekzai excelled in school, particularly in math and science. Two educational systems exist in parallel in Afghanistan. Religious education is the responsibility of clerics at mosques, and the government provides free academic education at state schools. From ages 7 to 13, pupils attend primary schools, where they learn the basics of reading, writing, arithmetic, and their national culture. Then, 3 years of middle school follow, where academic-style education continues. Students must pass an examination at the end of this phase if they wish to study further.

When Dr. Barekzai was in 12th grade, preparing for college, the Taliban gained control over Kabul and the neighboring regions, imposing harsh religious strictures, one of which forbade girls from attending school. “It was another difficult period for us, but fortunately, I passed the entrance exam for medical school and entered the Kabul University of Medical Sciences in 1998,” he shared. Dr. Barekzai explained that medical school in Afghanistan runs more than 7 years, and the first year is called PCB, which is intensive training in physics, chemistry, and biology. The next 5 years are devoted to medical training in the classroom, lab, and clinic, and the final year is an in-house internship in a hospital, which he did at the Indira Gandhi Children’s Hospital, also in Kabul.

“During this period, I became engaged to a woman who was part of our extended family and was living in a refugee camp in Pakistan. The Taliban had taken firm hold by then; but when I eventually went to Pakistan to marry my fiancée, the international forces entered Afghanistan and drove the Taliban out of Kabul. So, we returned, and I resumed medical school, attaining my medical degree in 2005. I am now the proud father of four girls and one son, and we live in Kabul along with my mother and father,” said Dr. Barekzai. 

A Decision to Pursue Surgical Oncology

Asked about his journey after medical school, Dr. Barekzai responded: “Working at the Indira Gandhi Children’s Hospital had a profound effect on my career. The pediatric surgeons were very helpful in our training. We were there assisting them, but, in reality, they were assisting us, too. So, during the 3 months I was assisting pediatric surgeons, my mind changed 180 degrees and I left all my preconceptions behind. Seeing the way the surgeons dealt with patients, I decided to become a surgeon myself. When I finished medical school, I went to work in a small private clinic, where I practiced general surgery. And then I decided to better my skills as a surgeon, I’d have to venture to a place where there were more high-volume procedures,” he explained.

Guest Editor

Chandrakanth Are, 

Chandrakanth Are, MBBS, MBA, FRCS, FACS

Dr. Are is the Jerald L. & Carolynn J. Varner Professor of Surgical Oncology & Global Health; Associate Dean for Graduate Medical Education; and Vice Chair of Education Department of Surgery, University of Nebraska Medical Center, Omaha.

Fortunately, Dr. Barekzai had two close friends, both 1 year ahead of him, who had gone to India to work in general laparoscopy and oncology surgery with Dr. Sameer Kaul and his team in the Apollo Healthcare Hospital in Delhi. They encouraged him to go to India for training, so he could better serve the challenges at home in Afghanistan.

“When I went to India and saw multiple complicated cases being treated in surgical oncology, I became very interested and continued my training as a fellow in surgical and clinical oncology. And at the end of 2007, I came back to Kabul and passed the entrance exam; shortly after, I began working in the general surgeries program in Aliabad Teaching Hospital in 2008. It was a 5-year program, which I finished in 2013. In between this, I attended more courses and conferences in India, went to Germany for a 3-week general surgery course training, and went to Egypt for some surgical conferences,” he said.

Delivering Cancer Care Without Radiation Therapy

Armed conflict in Afghanistan has continued for close to 40 years and has devastated its health infrastructure. The lack of a cancer care infrastructure has meant that many Afghans must seek cancer care in neighboring countries, such as Pakistan.

Asked about his current work schedule, Dr. Barekzai replied: “It all depends on the patients I must treat. In my fellowships, I did general and surgical oncology, as we don’t have such a specialized oncology practices in Afghanistan like in the West, divided into the three disciplines of medical, radiation, and surgical oncology. In fact, we don’t have a single radiation oncology facility in Afghanistan, so my work is a combination of medical and surgical oncology. When I do rounds in the clinic, which I do at the start of the week, which is Saturday in Afghanistan, I handle patients in the OR with my assistant; if chemotherapy is needed, that is done in the ICU ward. It is a challenging clinical setting, but we do the best, given our limited resources.”

Dr. Barekzai continued: “At one time, many years back, we had a cobalt-60 radiation treatment unit in Aliabad Hospital. However, during the war, the radiotherapy machine was destroyed. After that, due to security problems, Afghanistan is not allowed to start a nuclear medicine program, and we have no PET scan, which, of course, makes the delivery of cancer care that much more difficult.”

How many other surgeons are the in Afghanistan like you, Dr. Are asked. “Roughly, I think there are 4 or 5 surgeons over all of Afghanistan who have oncology training. There are a few other general surgeons; one or two from Pakistan, and some Russian-trained surgeons, especially in the military hospital.”

Sizable Challenges to Cancer Care

The Sehatmandi Project is the backbone of Afghanistan’s health system, providing care for millions of people through 2,331 health facilities. Since the Taliban gained power, major funding for the program has been withdrawn. Moreover, according to a report by the United Nations World Food Program, just 5% of households in Afghanistan have enough to eat every day.

“The time lapse from diagnosis to treatment is a serious challenge, as people must travel far distances to reach a clinic. This is made more difficult by our infrastructure, which was damaged severely during the war. The second challenge is the poor economic state of patients; even though there is government assistance, as you know, the cost of cancer therapies is very high, even posing challenges to wealthy nations like the United States, so one can imagine the challenges to a poor country such as Afghanistan,” said Dr. Barekzai. “There is also a huge awareness issue. Many people in Afghanistan believe a diagnosis of cancer is incurable, a death sentence, so they don’t bother with follow-up services. Then, there’s the huge problem of a lack of screening facilities and early detection programs, which all lower-income nations face. So, we have a host of challenges to our cancer care system. We must approach it piece by piece, otherwise the challenges are overwhelming.”

There is a huge awareness issue. Many people in Afghanistan believe a diagnosis of cancer is incurable, a death sentence, so they don’t bother with follow-up services.
— Ahmad Bashir Barekzai, MD

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Cancer Burden and COVID-19

Dr. Are shifted the conversation to the global perspective. He asked whether there are data to quantify Afghanistan’s cancer burden, and Dr. Barekzai responded: “We don’t have a robust and accurate data collection system. But if you ask anecdotally about my practice, and my associates’ practices, we have seen an increase in cervical cancer as well as cancers of the breast, colon, and stomach. And, again, our biggest challenge remains economic; when people are economically challenged, it exacerbates all public health issues, including cancer.”

As for COVID-19, there has been no apparent effect in Afghanistan, especially in terms of patients with cancer. Dr. Barekzai continued: “We had just 1 or 2 weeks when we canceled chemotherapies and planned surgical cases. For one, this is because most people in Afghanistan don’t believe COVID even exists. Our patients with cancer want their treatments; they are concerned with cancer, not COVID. So, our perception of the world is far different from that in the West. When the coronavirus pandemic was halting operations in other places, my colleagues and I just came back to the hospital and began taking care of our patients with cancer. That was our priority,” he explained. 

DISCLOSURE: Dr. Barekzai reported no conflicts of interest.