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PHS Pharmacist Plays Leadership Role in Afghanistan

Donna Young

After arriving in Kabul, Afghanistan, on January 25 to serve a two-month mission, the first task facing Captain J. Craig Hostetler, a pharmacist with the U.S. Public Health Service (PHS) Commissioned Corps, was determining how to fix an antiquated septic system at Rabia Balkhi Women's Hospital, a facility that admits about 36,000 patients annually and delivers about 40 babies daily.

More than two decades of war and ruling by the Taliban left Afghanistan's infrastructure in disrepair, said Hostetler, who was selected this past fall to serve as the first incountry senior adviser for the Department of Health and Human Services (HHS) Office of Global Health Affairs.

Hospital infrastructure problems can "impact patient care and delivery of quality health care," said Amar Bhat, director of the Asia and Pacific regions for Global Health Affairs.

Hostetler worked with Rabia Balkhi's administrator to quickly secure $15,000 in emergency funds for a new septic system.

Not a typical pharmacist role, Hostetler said by phone from Afghanistan. However, he added, his 31-year PHS pharmacist experience15 years of which was with the Indian Health Service (IHS)is helping him in his current scope of responsibilities, which includes coordinating a range of reconstruction projects in Afghanistan and advising the country's Ministry of Public Health on various health care issues.

PHS trains for the world. Global Health Affairs chose Hostetler for the job in Afghanistan partly because of his experience providing pharmacy services to American Indians, including the Cherokee, Lakota, and Navajo tribes, in isolated regions of the United States, Bhat said.

Rear Admiral Richard S. Walling, director of the Americas and Middle East regions for Global Health Affairs, and PHS's chief pharmacist officer, said that PHS pharmacists have the opportunity to gain broad leadership skills.

IHS, he added, is a "wonderful training ground for international activity" because pharmacists learn about values and aspects of other ways of life and traditions that teach clinicians to be "culturally sensitive" when delivering services.

Walling praised Hostetler as a "prime model or example" of a pharmacist who has gained that knowledge.

Hostetler served permanent assignments with IHS in Arizona, Oklahoma, and South Dakota, and several temporary assignments in various locations, including one month during the winter in Point Barrow, Alaskathe northernmost spot on the North American continent.

A person who volunteers to go to Alaska during the winter, Hostetler chuckled, is the "same kind of person who volunteers to go to Afghanistan during the war."

Hostetler also served twice as acting hospital administrative officer at IHS facilities.

He oversaw one IHS facility's process to regain its lost accreditation from the Joint Commission on Accreditation of Healthcare Organizations.

Hostetler said he was asked to lead the facility's effort to regain accreditation because the "pharmacy was the only department that passed with flying colors" during the previous accreditation process. The facility successfully regained its accreditation by the next year, he noted.

"I didn't do all the work but was able to garner the resources and put the teams together to coordinate the activities . . . that were needed to improve the quality of care at the hospital to get the accreditation back," he said.

Global health needs pharmacists. Hostetler's assignment in Afghanistan, Walling said, "shows that we have entered a new era of health, which is really global health, and we've started to recognize it. We're recognizing the fact that all the professionals need to take a part in that, including pharmacy. It's an excellent example of how we can use pharmacists. It also is going to become more and more important for pharmacy itself to expand outside, to move and help countries develop clinical pharmacy programs."

Before his assignment in Afghanistan, Hostetler served since 1999 with the Pharmacy Services and Assistance Branchformerly the Office of Pharmacy Affairsthe office that oversees the 340B program for the Healthcare Resources and Services Administration and helps safety-net facilities.

He was also the chair of the pharmacists advisory committee for the Office of the U.S. Surgeon General.

It was while serving in the chair role that Hostetler first saw the notice in October 2003 about the senior adviser position in Afghanistan. He was responsible for e-mailing the job announcement to PHS pharmacists on a listserver. However, Hostetler did not read the notice before sending it.

But Walling did read the notice and immediately contacted Hostetler and advised him to apply for the job.

"I laughed, and still didn't read the announcement," Hostetler said. "I didn't have international experience and didn't think I was qualified."

But after receiving a second call from his boss, Jimmy Mitchell, at the 340B program, and another call from one of his PHS colleagues, who urged him to apply for the job, Hostetler decided to send Bhat his resumé.

"I think the positions that I have taken because other people suggested I do it, that may or may not have looked like the most advantageous position for me at the time, those are the jobs that I enjoyed the most and were the most challenging and rewarding," Hostetler opined.

"The positions that I took out of selfishness or just thinking that this is a location I wanted to be [in], didn't turn out to be my most challenging and rewarding jobs," he added. "I've learned that over the years, that sometimes other people can assess where your talents are and skills are, and I've relied on that, and I've had great people along in my career, good mentors, that have helped me stretch my wings and take on some challenges that I wasn't sure I was qualified for or able to do."

Hostetler has an office at the U.S. military's compound in Kabul and a second office at the Afghanistan Ministry of Public Health.

Many of the people he works with on the reconstruction projects are health care workers and other personnel serving in the U.S. military reserves and the National Guard.

Many of those same people, he added, previously served in Bosnia helping with that country's reconstruction.

"It's amazing the capabilities the military has," Hostetler said.

Up-to-date training is vital. One of Global Health Affairs' main projects at the Rabia Balkhi Women's Hospital, he noted, is establishing the maternal and child health teaching clinic, a medical residency program.

HHS had hoped to start the program last year, but "the depths of the problems of the hospital have been greater than we originally envisioned," Bhat said.

HHS and officials from the Centers for Disease Control and Prevention (CDC) discovered through assessments the agencies conducted last year that before they could implement a residency training program, senior physicians at the hospital needed to be trained in up-to-date medical methods of care, he said.

"In the assessments, we realized that one of the glaring deficiencies . . . is that the physicians had not had the benefit of continuing medical education," he said. "The medicine they are practicing and teaching to their younger physicians was hopelessly, hopelessly outdated. Plus, they had a significant lack of equipment as well as trained staff and drugs to work with."

A training program for the attending physicians that had intended to be a "refresher course to get them up to speed" turned out to be "a lot more training than we anticipated," Bhat said.

Many of the hospital's physicians did not have sufficient medical school training and lacked "a strong understanding of the basic sciences behind what they were doing," he said. "So they didn't know why they were doing what they were doing, and when something went wrong they didn't understand how to respond. In addition, we realized that the hospital itself is really hobbled by numerous infrastructural and administrative problems; things that you wouldn't necessarily discover when you're just kind of taking a tour of the place."

Infrastructure matters. The hospital lacked a maintenance staff, Bhat said, which was one reason that led to the sewer system problems.

"There was no good mechanism for getting rid of waste, especially biohazardous waste," he said. "So we realized in order to have a quality training program we needed to have a higher quality environment in which to work in. We needed to have a more smoothly running hospital."

The Department of Defense is overseeing a maintenance contract for the hospital, Bhat said.

The facility also did not have a record-keeping system, he noted.

CDC is helping the hospital develop a "rudimentary record-keeping system," Bhat said, and the agency is also helping the health care staff develop standardized procedures for maternal and infant care. CDC is also studying infant and maternal mortality rates.

Two consultant hospital administrators from the Department of Veterans Affairs and IHS obstetric and gynecology specialists and engineering consultants are assisting with various projects at Rabia Balkhi, Hostetler said. The facility will serve as a model for Afghanistan's other hospitals, he added.

HHS is hoping to have the residency program implemented before the end of the year, Bhat said.

Providing pharmacy services. In his role as an adviser to the Afghani government, Hostetler is working with the health ministry's hospital group to develop a comprehensive health care plan.

"We're defining the types of hospitals and what services will be provided at those hospitals and a referral system that would meet the needs of people that have a higher degree of care needs," Hostetler said.

During his first meeting with the ministry's hospital group, he noticed that a vital type of service was missing from the plan: pharmacy services.

Hostetler said his first recommendation was to add pharmacy services for all hospitals, "and it was immediately adopted by the group."

Primary care services. In his senior adviser role, Hostetler will also help develop a plan for the country's primary care services.

One goal the country has established so far, he noted, is that, "within 12 months, 600,000 children under the age of five years will have access to health care less than a four-hour walk" from home.

"There will be a lot of children that are going to be walking."