Letter to the Editor. Humanitarian care: a plea for the consideration of ethical foundations and secondary effects

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TO THE EDITOR: We read with interest the report by Forbes7 (Forbes JA: Elective neurosurgical humanitarian care in a deployed setting. Neurosurg Focus 45(6):E8, December 2018). Dr. Forbes presents a series of procedures performed on a cohort of 49 local Afghani patients during his deployment to Afghanistan in 2014. His stated intentions are the maintenance of proficiency for his surgical team and to “win hearts and minds” amongst the local population. We are certain that his efforts were well intentioned but we have concerns regarding his foundation for the provision of care and his understanding of basic principles of humanitarian care, as well as the role of medical operations in counterinsurgency warfare.

We acknowledge and agree with the need for such care. Worldwide access to surgical care is poor. It is estimated that 5 billion people currently lack access to safe, affordable surgical and anesthetic care.8 An estimated 5 million essential neurosurgical cases per year are not addressed in low- and middle-income countries.5 Multiple organizations, including the World Federation of Neurosurgical Societies (WFNS), the Foundation for International Education in Neurological Surgery (FIENS), and the International Society for Pediatric Neurosurgery (ISPN) are currently engaged in systematic efforts to develop strategies to address these deficits. In addition there is a long history of individual neurosurgeons being engaged in these endeavors.4

The desire to participate in humanitarian care is fundamental to the practice of medicine and it requires the clinician to “go to an area where good care is not available, to provide services that can make a huge difference in the health and welfare of a fellow human being, to provide this service freely and without personal gain.”11 There are multiple examples of humanitarian efforts by neurosurgical providers over the past several decades.1,11 As evidenced by the Forbes article and others,3 noncombatants have frequently been cared for at deployed military medical facilities in Iraq and Afghanistan.

Sadly, no matter how well intentioned, any medical or surgical mission has the potential to do harm. Forbes references an outstanding article regarding ethical considerations in the delivery of humanitarian care. Welling et al.12 describe the “sins” of humanitarian medicine to include “leaving a mess behind, failing to match technology to local needs and abilities, failing to have a follow-up plan, allowing politics, training, or other goals to trump service while representing the mission as ‘service,’ and doing the right thing for the wrong reason.” They characterize the mindset for a successful humanitarian mission in which the provider would “go forth with pure motives, with a well-thought-out plan of action, including host nation physicians, avoiding the types of operations that lend themselves to long-term complications, and with a teachable, humble attitude.” We are concerned that Dr. Forbes has not fully absorbed this message.

Humanitarian care cannot be provided in a vacuum. Providers must understand local religious, economic, and political culture in the region where they practice in order to avoid pitfalls that are otherwise unseen.2 They must understand and interact with the local and regional healthcare system. They must define an appropriate scope of practice to maximize the potential for good patient outcomes and ensure that appropriate follow-up care is available on departure. In the absence of appropriate follow-up and audit, the surgeons who violate these rules rarely see the poor results they produce.

Forbes’ talent and enthusiasm is obvious and well described by the operative details he provides through the bulk of this article. Our major concerns lie in the detail that is not included regarding critical considerations in the delivery of humanitarian care. Forbes fails to explore whether the interventions performed were appropriate to the local social, medical, and political circumstances. We are unclear regarding his interaction with the local healthcare system, and he does not elaborate on his interaction with the “Afghan neurosurgical trainee” whom he only mentions in passing. His comment regarding case 3 that “for unknown reasons, treatment was not rendered” to a 25-year-old Afghani with a large intraventricular tumor and hydrocephalus is unsatisfactory and possibly implies a poor understanding of the family circumstances as well as the local surgical facilities and capabilities.

Although the Forbes paper introduces several topics of interest to the deploying military provider, we question if his manuscript addresses them in a meaningful fashion. As a result of lower combat intensity, US casualties in combat have steadily declined over the past decade. We agree that a decrease in combat casualties has created a legitimate concern for the erosion of skills during surgical deployments.6 Forbes rightly highlights this as a problem, one that will require thoughtful and multifaceted solutions. Examples include physician leaders engaging in mission planning to ensure that maintaining the competencies of surgical assets are considered on equal footing with security, logistics, and overall military strategy.6 Shin et al.10 discuss the role of civilian-military partnerships before and after deployments to maintain proficiency in active-duty providers engaged in low-volume surgical practice. However, engaging in care exceeding local standards with limited or no engagement of the local healthcare system and unsustainable patient follow-up practices for the purposes of maintenance of proficiency under the guise of “humanitarian care” cannot be condoned from any perspective.

Finally, Forbes discusses the delivery of humanitarian care as “in line with the counterinsurgency platform originally advocated by General Petraeus.” While seemingly counterintuitive, we would assert that the opposite is in fact true. Rice and Jones9 provide an outstanding review of the role of medical operations in counterinsurgency warfare.8 They state that in the setting of counterinsurgency operations, medical operations should be conducted “only if they are likely to cause the local population to become more reliant on and confident in their indigenous medical institutions, supporting the strategic counterinsurgency goal of legitimizing the native government.” Forbes lists 5 cases performed as “revisions following previous surgeries performed by outside surgeons.” One could infer a negative impact that such cases had on perceptions of the local population regarding the capability of Afghani medical facilities. Rather than establishing trust and confidence, medical missions may in fact delegitimize host-nation government and healthcare institutions, running counter to the desired military objective.

In summary, although Forbes was able to perform a series of 49 non–combat-related cases in an austere environment, his contention that the humanitarian care provided was implemented effectively or safely cannot be supported based on the information provided. We question if military objectives supporting a counterinsurgency effort were achieved. We strongly question the wisdom of applying first-world interpretations of beneficence and justice to care delivery in the third world by providers who are poorly informed about local culture, politics, and the indigenous healthcare system. Although we cannot disagree that increased surgical volume improves the proficiency of the surgical team, it undermines the beneficence of a mission that was deemed “humanitarian.” We plead for careful consideration prior to providing elective neurosurgical humanitarian care in a deployed environment.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Albright AL: Reflections on developing pediatric neurosurgery in Sub-Saharan Africa. J Neurosurg Peds 18:1271382016

  • 2

    Awori JStrahle JOkechi HDavis MC: Implications of patient-borne costs associated with pediatric neurosurgical care in eastern Africa. J Neurosurg Pediatr 18:1161242016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Burnett MWSpinella PCAzarow KSCallahan CW: Pediatric care as a part of the US Army medical mission in the global war on terrorism in Afghanistan and Iraq, December 2001 to December 2004. Pediatrics 121:2612652008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Dempsey RJ: Editorial. Global neurosurgery: the role of the individual neurosurgeon, the Foundation for International Education in Neurological Surgery, and “service through education” to address worldwide need. Neurosurg Focus 45(4):E192018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Dewan MCRattani AFieggen GArraez MAServadei FBoop FA: Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg 130:105510642019

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Edwards MJWhite CERemick KNEdwards KDGross KR: Army general surgery’s crisis of conscience. J Am Col Surg 226:119011942018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Forbes JA: Elective neurosurgical humanitarian care in a deployed setting. Neurosurg Focus 45(6):E82018

  • 8

    Meara JGLeather AJMHagander LAlkire BCAlonso NAmeh EA: Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:5696242015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Rice MSJones OJ: Medical operations in counterinsurgency warfare: desired effects and unintended consequences. Mil Rev 90:47572010

    • Search Google Scholar
    • Export Citation
  • 10

    Shin DHHooten KGSindelar BDCorliss BMCarlton WRYCarroll CP: Direct enhancement of readiness for wartime critical specialties by civilian-military partnerships for neurosurgical care: residency training and beyond. Neurosurg Focus 45(6):E172018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Warf BCDagi ARKaaya BNSchiff SJ: Five-year survival and outcome of treatment for post-infectious hydrocephalus in Ugandan infants. J Neurosurg Ped 8:5025082011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Welling DRRyan JMBurris DGRich NM: Seven sins of humanitarian medicine. World J Surg 34:4664702010

INCLUDE WHEN CITING DOI: 10.3171/2019.4.FOCUS1919.

Response

The following is a response to the letter to the editor submitted by Martin et al. In this letter, the authors question foremost “the wisdom of applying first-world interpretations of beneficence and justice to care delivery in the third world.” In the ensuing response, I will identify criticisms put forth by Martin et al. that I believe are valid. I will clearly outline the robust ethical construct in place at the Craig Joint Theater Hospital (CJTH), which I believe has been inaccurately portrayed by Dr. Martin. I will clarify the very important issue of postoperative follow-up. I will seek to ascertain Martin et al.’s impression of access to basic neurosurgical care in Afghanistan. I will answer specific questions put forth in their letter, including those regarding the care of the patient described in case 3. Ultimately, I will ask the reader to honestly evaluate the serious implications of the philosophy espoused by Martin, Harkness, and Edwards—which would have sought to fundamentally deny access to neurosurgical care to the patients discussed in the original manuscript.

On valid criticisms: I believe Dr. Martin is correct to criticize wording used in the introduction, which was written in such a manner to highlight the potential benefits of provision of humanitarian care (HC) to military leadership. While only military leadership has the power to reestablish HC at Bagram, the sole concern of the providers who delivered care was benefit to patient and family. In failing to convey this message, I have neglected to honor the hard work of so many nurses, physicians, and medical technicians who worked tirelessly and compassionately in this pursuit.

On the robust ethical construct in place at CJTH: every operation performed at CJTH required validation at a weekly ethics panel held on Monday nights. This process is clearly referenced in the paper (page 8, paragraph 2).

The weekly multidisciplinary ethics panel was mandatory for all providers who participated in humanitarian care. In this panel, we meticulously reviewed the clinical history, findings on physical examination and available imaging, the effect of the untreated condition on quality of life, the natural history of the disorder, alternative options for treatment that might exist in the region, associated surgical risks, and anticipated benefits. In these meetings, emphasis was placed on provision of services able to provide a substantial difference in the health and well-being of a fellow human being. No surgery could be approved without consensus from the group—which included approximately 15 military providers. On many nights, we agonized for hours over the best course of action for the patients we discussed. Our perspective changed as our understanding of the capabilities of adjacent institutions in the region evolved. Dr. Martin’s letter incredulously fails to acknowledge these weekly ethics panels, despite their clear reference in the original manuscript and additional written and verbal communications provided to him confirming both their crucial role in this discussion and their inaccurate representation in his response, prior to final publication of his letter. Such an omission can only be viewed as deliberate. As such, his letter falls short of an honest evaluation of patient care at CJTH.

On postoperative follow-up: It is critical to recognize the difference between data presented in the manuscript, which are inherently limited to Neurolog entries logged during the primary author’s deployment, from actuarial, comprehensive follow-up provided. The manuscript clearly states that various patients required additional follow-up beyond dates reported in the Results section. The data available for retrospective review was limited to personal Neurolog entries, which by definition did not include information from additional visits with antecedent deployed neurosurgical personnel (it would have been exceedingly difficult to retrospectively obtain this information, which is stored locally at Bagram Air Force Base [AFB]). As a rule, patients who underwent spinal decompression and/or peripheral nerve surgery noted to be doing well 3 months postoperatively were not required to return for additional, scheduled follow-up. For all other patients, lengthier follow-up was required. Dr. Martin’s characterization of postoperative follow-up as “unsustainable” is categorically incorrect. During time spent deployed, I routinely evaluated patients receiving humanitarian care who had been operated on as many as 5 years prior to my arrival by preceding, deployed neurosurgeons. To date, patients with a history of a surgical procedure performed at CJTH are still able to gain access to the hospital and/or outpatient clinic through the CJTH portal of entry.

On Martin et al.’s impression of access to basic neurosurgical care in Afghanistan: in their letter, Martin et al. suggest that the providers at CJTH had a limited understanding of the local and regional healthcare systems. They imply that the neurosurgical care provided at CJTH could have been freely accessed elsewhere in the region. During 6 months spent at Bagram working hand in hand with Afghan physicians, we became painfully familiar with the profound barriers to medical and surgical care routinely faced by local civilians. Early in our experience, we evaluated an adolescent male with a complex brain tumor known to be benign from a previous biopsy performed in Pakistan. We worried about the capabilities of CJTH and about potential operative morbidity associated with resection. We did not fully understand the capabilities of adjacent institutions. The patient was discussed at the CJTH multidisciplinary panel, where the group recommended that the patient seek neurosurgical care outside CJTH. He was seen very soon after by a neurosurgeon in Kabul, who recommended that he return to Pakistan. Surgical care was never rendered. Six weeks later the young man herniated. His brother carried him through the Korean gate of entry that afternoon. Together, we grieved with the family. We pored over the decision we had made to turn the young man away. Martin et al. are unlikely to protest our decision to deny neurosurgical care to this patient. They would have disregarded any attempt at treatment as “outside an appropriate scope of practice” and/or “out of touch with local religious, economic, and/or political culture.” However, we were left with the reality that the young man’s death could have been prevented with timely and appropriate neurosurgical intervention. Analogous situations presented themselves in future encounters—as described in cases 3 and 6 in the manuscript. These patients were provided with appropriate neurosurgical care at CJTH and recovered uneventfully following surgery.

Afghanistan is one of the poorest countries in the world.1 It has the third highest infant mortality rate in the world.4 The medical establishment has been decimated by a state of near-perpetual warfare that has raged on for the past 40 years.3 Afghanistan is known as one of the most dangerous places in the world to provide humanitarian aid—a designation that has severely limited the ability of outside physicians and surgeons to provide vital humanitarian assistance.2 Collectively, these circumstances have resulted in profound barriers to basic medical and surgical care. It was an incredible privilege to interact with and work beside the people and medical providers of Afghanistan, who routinely handled adversity that would seem insurmountable to many other cultures with remarkable grace, strength, and dignity. Martin et al. suggest the providers at CJTH had a limited understanding of local healthcare systems. They imply that the patients we took care of would have had unobstructed access to equivalent neurosurgical care elsewhere in the region. I vehemently disagree and openly question the inattentive nature of these assessments.

On specific questions posed by Martin et al.:

  • “[H]e does not elaborate on his interaction with the ‘Afghan neurosurgical trainee’ whom he only mentions in passing.” I worked closely with an Afghan neurosurgeon at CJTH, who was able to scrub in on more than 20 surgical procedures. He routinely provided this assistance, despite a long commute to and from Bagram AFB prior to the start and after the finish of each day. Following completion of the deployment cycle, we have remained in touch regarding neurosurgical issues he encounters in clinic—including care of patients we evaluated and treated together during the 2014 deployment cycle. It was a privilege to have worked with him and possibly played some small role in his surgical education.

  • “We are unclear regarding his interaction with the local healthcare system….” In addition to standard collaboration with the Afghan neurosurgeon discussed above, we routinely worked with a team of Afghan medical providers at both the Korean hospital and CJTH that included multiple physicians, interpreters, medical liaisons, nurses, and pharmacologists. These individuals directly interacted with local institutions and provided essential information on alternative options for care in the region. Information that they provided was routinely discussed at our weekly multidisciplinary ethics panels. Their involvement was crucial and provided additional long-term points of contact in the community for patients receiving care.

  • “His comment regarding case 3 that ‘for unknown reasons, treatment was not rendered’ to a 25-year-old Afghani with a large intraventricular tumor and hydrocephalus is unsatisfactory and possibly implies a poor understanding of the family circumstances as well as the local surgical facilities and capabilities.” Martin’s comments here are unsatisfactory. There is no question this patient would have died without surgical intervention. His surgery proceeded uneventfully, with full recovery after radiographic complete resection of the tumor. As with every single other patient I operated on at CJTH, this patient was given my email address after surgery. He was gracious enough to send me a picture with an update in 2016. On 5/9/17, he emailed me with the devastating news that the tumor had recurred. A copy of this MRI report was provided to Dr. Martin after receiving his letter.

  • On the philosophy espoused by Martin et al.: in the early part of their letter, Martin et al. champion the provision of services able to provide a substantial difference in patient health and well-being. In subsequent comments, they criticize procedures they perceive as outside “an appropriate scope of practice” without any consideration of effect on patient quality of life. Martin et al. irresponsibly avoid a discussion of what would have happened to these patients without treatment. The reader must honestly evaluate these comments with attention to the serious implications regarding patient care not openly discussed. Martin would have denied care to the patient in case 4, who undoubtedly would have progressed to complete paralysis without treatment. Instead, this patient regained the ability to ambulate—with reclamation of full strength in her lower extremities postoperatively. He would have denied care to the patient in case 3, who would have died unnecessarily without surgery—but instead went on to resume a normal life postoperatively. These patients are nameless and faceless to Martin, but they are patients and families we came to know well. They are patients we carefully approved for treatment after a long discussion in a peer-reviewed setting based on the substantial improvement in quality of life we felt we could provide. I openly question the decision to render broad and overreaching value assessments by authors with minimal knowledge of individual patient circumstance and an incomplete understanding of the profound ramifications associated with denial of care.

The interventions provided at CJTH were not performed in isolation. Procedures with greater complexity were performed only after consistently excellent results had been demonstrated with more routine procedures and only if the patient in question faced severe deterioration in quality of life (e.g., hemiplegia, blindness, paralysis) or death without treatment. These procedures were subject to routine peer-reviewed scrutiny before surgery in a weekly multidisciplinary ethics panel and after surgery at a monthly morbidity and mortality conference. Throughout our deployment cycle, we earnestly and resolutely sought to deliver humanitarian care that would provide the greatest amount of good and the least amount of harm.

In every single patient who underwent humanitarian surgery at CJTH, approximately 15 military physician officers expressed with consensus that offering treatment was the ethically correct course of action. These physicians saw the patients before surgery, in the immediate perioperative period, and after surgery. They were painfully familiar with the profound barriers to basic neurosurgical care that these patients faced and the serious implications associated with denial of treatment. Importantly, these providers were also familiar with the excellent clinical results that could be consistently achieved with meticulous preparation—even in a setting with limited resources. The care we provided 1) was ethically sound and 2) provided a treatment that otherwise would not have been available to the patients involved. The treatments rendered 3) successfully altered the course of the disease with outcomes comparable to what would be expected in the US and other developed countries, and 4) in completing the aforementioned objectives, also helped to further the surgical education of Afghan providers.

The Craig Joint Theater Hospital has provided a stable neurosurgical presence at Bagram AFB since 2007. Inside this hospital, at this very moment, scores of highly trained military physicians and surgeons routinely spend only a fraction of their deployment cycle directly involved in patient care and/or medical education. These providers have the time and the expertise and the compassion to provide vital assistance to a population of local civilians and providers in desperate need of humanitarian aid that will not be filled in the absence of a military presence. Martin, Harkness, and Edwards argue we should do less. I argue we can and should do more, and plead that first-world interpretations of beneficence and justice be extended to care delivery in the developing world.

References

  • 1

    Harrington J: From the Solomon Islands to Liberia: these are the 25 poorest countries in the world. USA Today. November 29 2018 (https://www.usatoday.com/story/money/2018/11/29/poorest-countries-world-2018/38429473/) [Accessed June 11 2019]

    • Search Google Scholar
    • Export Citation
  • 2

    McCarthy N: The most dangerous countries for aid workers [infographic]. Forbes. October 5 2015 (https://www.forbes.com/sites/niallmccarthy/2015/10/05/the-most-dangerous-countries-for-aid-workers-infographic/) [Accessed June 11 2019]

    • Search Google Scholar
    • Export Citation
  • 3

    Sharp TWBurkle FM JrVaughn AFChotani RBrennan RJ: Challenges and opportunities for humanitarian relief in Afghanistan. Clin Infect Dis 34:S215S2282002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Viswanathan KBecker SHansen PMDhirendra KKumar BNiayesh H: Infant and under-five mortality in Afghanistan: current estimates and limitations. Bull World Health Organ 88:5765832010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Correspondence Jonathan E. Martin: jmartin03@ccmckids.org.

INCLUDE WHEN CITING DOI: 10.3171/2019.1.FOCUS1917.

Disclosures The authors report no conflict of interest.

© AANS, except where prohibited by US copyright law.

Headings

References

  • 1

    Albright AL: Reflections on developing pediatric neurosurgery in Sub-Saharan Africa. J Neurosurg Peds 18:1271382016

  • 2

    Awori JStrahle JOkechi HDavis MC: Implications of patient-borne costs associated with pediatric neurosurgical care in eastern Africa. J Neurosurg Pediatr 18:1161242016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Burnett MWSpinella PCAzarow KSCallahan CW: Pediatric care as a part of the US Army medical mission in the global war on terrorism in Afghanistan and Iraq, December 2001 to December 2004. Pediatrics 121:2612652008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Dempsey RJ: Editorial. Global neurosurgery: the role of the individual neurosurgeon, the Foundation for International Education in Neurological Surgery, and “service through education” to address worldwide need. Neurosurg Focus 45(4):E192018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Dewan MCRattani AFieggen GArraez MAServadei FBoop FA: Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg 130:105510642019

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Edwards MJWhite CERemick KNEdwards KDGross KR: Army general surgery’s crisis of conscience. J Am Col Surg 226:119011942018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Forbes JA: Elective neurosurgical humanitarian care in a deployed setting. Neurosurg Focus 45(6):E82018

  • 8

    Meara JGLeather AJMHagander LAlkire BCAlonso NAmeh EA: Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:5696242015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Rice MSJones OJ: Medical operations in counterinsurgency warfare: desired effects and unintended consequences. Mil Rev 90:47572010

    • Search Google Scholar
    • Export Citation
  • 10

    Shin DHHooten KGSindelar BDCorliss BMCarlton WRYCarroll CP: Direct enhancement of readiness for wartime critical specialties by civilian-military partnerships for neurosurgical care: residency training and beyond. Neurosurg Focus 45(6):E172018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Warf BCDagi ARKaaya BNSchiff SJ: Five-year survival and outcome of treatment for post-infectious hydrocephalus in Ugandan infants. J Neurosurg Ped 8:5025082011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Welling DRRyan JMBurris DGRich NM: Seven sins of humanitarian medicine. World J Surg 34:4664702010

  • 1

    Harrington J: From the Solomon Islands to Liberia: these are the 25 poorest countries in the world. USA Today. November 29 2018 (https://www.usatoday.com/story/money/2018/11/29/poorest-countries-world-2018/38429473/) [Accessed June 11 2019]

    • Search Google Scholar
    • Export Citation
  • 2

    McCarthy N: The most dangerous countries for aid workers [infographic]. Forbes. October 5 2015 (https://www.forbes.com/sites/niallmccarthy/2015/10/05/the-most-dangerous-countries-for-aid-workers-infographic/) [Accessed June 11 2019]

    • Search Google Scholar
    • Export Citation
  • 3

    Sharp TWBurkle FM JrVaughn AFChotani RBrennan RJ: Challenges and opportunities for humanitarian relief in Afghanistan. Clin Infect Dis 34:S215S2282002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Viswanathan KBecker SHansen PMDhirendra KKumar BNiayesh H: Infant and under-five mortality in Afghanistan: current estimates and limitations. Bull World Health Organ 88:5765832010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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