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Pathology In Afganistan New Atlas of Non Tumor Pathology The Foundations of Pathology in the United Kingdom
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Pathology in Afghanistan - Revisited
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From September 1965 to March 1968, I had the opportunity to work in Kabul as WHO Professor of Pathology in the Faculty of Medicine. Some of my experiences have been published (Sobin LH. Cancer in Afghanistan. Cancer 1969;23:678-88). Now, over thirty years later, it is interesting to summarize these observations so that comparisons can be made with the present and future medical situation. I suspect that little has changed owing to the long period of conflict and lack of development.
Cutaneous Leishmaniasis Population and Health Facilities The population of Afghanistan was estimated at about 14 million with 300,000 living in Kabul. Most males were engaged in agriculture and sheep-raising. The main exports were karakul skins, fruits, and carpets. The Faculty of MedicineÕs Department of Pathology was the sole histopathologic diagnostic laboratory in the country. Material was received from the 6 major hospitals in Kabul, comprising around 1200 beds. A few specimens were sent from provincial hospitals. However, the provincial population was further represented owing to the common practice of patients coming to Kabul for care that was beyond the capacity of smaller hospitals. In fact, less than 30% of cancers were from Kabul residents, whereas over 90% of specimens were from Kabul hospitals. Females accounted for more than 50% of surgical specimens, particularly uterine curettages. There were about 700 Afghan physicians in 1966, i.e., 1 physician per 20,000 people.
Child with Smallpox General Disease Patterns Infectious diseases were prominent. Of these, water-borne infections such as bacillary dysentery, typhoid fever, amebiasis, viral hepatitis, and parasitic infections were endemic. Tuberculosis and trachoma were widespread. Occasional cases of smallpox and leprosy were found. Malaria had been greatly reduced owing to an eradication campaign. Echinococcosis and cutaneous leishmaniasis were not uncommon. Schistosomiasis did not appear to occur. Nontuberculous pulmonary diseases such as chronic bronchitis and bronchiectasis were common. Rheumatic heart disease was frequent, but arteriosclerosis was relatively rare. Goiter was endemic in the mountainous Hindu Kush. Urinary calculi, particularly in young males, were common. Protein malnutrition in recently weaned children was frequent and often exacerbated by diarrheal disease. Burns were common, often due to starting household fires with gasoline. Traffic accidents were frequent. One interesting cause of these in women was tripping and falling over obstacles, and being hit by animals or vehicles from the side. This was attributed to the impaired peripheral vision caused by women wearing the all-enveloping burkas. Tumor patterns A tumor registry was established in the pathology department and collected 895 benign and malignant tumors during my tenure. The major sites of cancer in Afghan males were: skin (particularly the face), lymphoid system, soft tissues, eye (conjunctiva), testis, hematopoietic system, stomach, esophagus, and bone. The major sites of cancer in Afghan females were: breast, skin, soft tissues, ovary, lymphoid system, esophagus, rectum, and eye. These were the more accessible sites rather than deep locations, reflecting the lack of highly developed medical facilities and an active autopsy service. Notably absent from the major sites were oral and uterine cervical carcinomas. One might expect a high frequency of oral carcinoma (as in neighbouring India and Pakistan) owing to the widespread use of naswar, a moist mixture of ground tobacco and lime [Ca(OH)2] placed under the tongue or against the buccal wall. One might also have expected to find a high incidence of uterine cervical carcinoma, but it was of much lower frequency than in neighbouring Iran and Pakistan. Under-reporting was an unlikely explanation, as women comprised a greater proportion of surgical specimens than did men. Some cancers showed interesting geographical or ethnic concentrations: there was a disproportionate concentration of esophageal squamous cell carcinoma from regions north of the Hindu Kush and among Uzbeks and Turkmen. A similar situation was present in the neighbouring portions of Iran and the former Soviet Union. Local physicians attributed this to the common practice of ingesting extremely hot tea and soups. Esophageal carcinoma was uncommon in the remainder of the country as in Pakistan, probably related to the rare use of alcohol. Testis germ cell malignancies were likewise more frequent in those living north of the Hindu Kush. Some local physicians believed that trauma from horseback riding was a factor. Horseback riding was much more common in the north than elsewhere.
The high rate of skin and conjunctival carcinoma in men can be explained by the abundant sunshine, high altitude (Kabul is at 5900 feet [1970 metres]), with its attendant high ultraviolet level, a high proportion of outdoor laborers, not heavily pigmented skin, and brimless headwear (turbans). Women had many fewer facial skin cancers, owing to their traditional outdoor burkas, which resulted in almost complete covering of the face, and the fact that they spent more time indoors than did the men. However, skin cancers of the lower extremity were as frequent in women as they were in men. Over 40% of the skin carcinomas on the lower extremities were associated with burn scars and osteomyelitic fistulas. It will be interesting to see if this disease pattern changes as peace and development hopefully occur. Leslie H. Sobin,
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FACES OF THE IAP
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An informal dinner meeting in the home of Vincenzo and Christine Eusebi. Christine prepared a wonderful Italian style meal.
Seated - Paolo Scarani, Vincenzo and Christine Eusebi (Bologna, Italy). Standing - Pichet Sampatanukul (Chulalongkom University, Bangkok), Thiti Kuakpaetoon (Rajanuithi Hospital, Bangkok), Tsheri Dorji, Jongkolnee Settakorn (Chiang Mai University, Chiang Mai).
Stephen Vogel (President of the IAP) with Njue Mojes Gautoki (Nyeri, Kenya) and Robin Cooke (Editor of the News Bulletin)
Lunch break : Jutta Luttges (Germany), D. Orhan, O. Tulunay (Turkey), Elizabeth Muiu, Jean-Michel Coindre (France), Mary Miller (New Zealand), Sabine Ruthdorf (Germany), Happy Tang (Australia) |
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HOT TIP FOR AMSTERDAM 2002 Don't miss the Sakura Walking Tour of the historical city of Leiden. |
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Editorial Enquiries:
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Boy
wearing a turban and selling cigarettes
