The U.S. military’s days in Afghanistan may be numbered, but for many humanitarian workers—including Anne E. Goldfeld, associate professor of medicine at Harvard Medical School (HMS)—the work is just beginning.

Goldfeld, along with two researchers from the non-profit American Refugee Committee (ARC), returned from a two-week mission to Afghanistan to treat tuberculosis among Afghani refugees last month.

“The situation is urgent,” says Goldfeld, who besides being a board member of ARC is also an infectious disease specialist at the Brigham and Women’s Hospital.

Facing disease, drought and poor nutrition, thousands of refugees have flocked to Afghanistan-Pakistan border. Most, newly arrived and seeking shelter from the U.S. war campaign, are in desperate need of medical attention.

Goldfeld visited three refugee camps in northwest Afghanistan, in addition to meeting with newly installed officials in Kabul who endorsed ARC’s efforts.

In Dire Need

Afghanistan currently has one of the worst tuberculosis problems in the world. It is estimated that 60,000 to 70,000 new cases of tuberculosis are diagnosed each year in Afghanistan and that 15,000 people die of the disease, according to the most conservative estimates.

As of now, half of those with the disease will die in five to nine months unless they get help—and the war-torn country is hardly equipped to deal with this epidemic.

“The health system is completely decimated,” says Joe Bock, interim executive director of the ARC. “The World Health Organization estimated millions of dollars to rebuild Afghanistan’s health system.”

While tuberculosis was a serious problem long before the words Taliban and al-Qaeda were part of the American vocabulary, the recent war in Afghanistan has only made matters worse.

“Crowding, cold, and lack of supplies in the refugee camps foster the spread of the contagious, airborne disease,” Goldfeld says.

“In addition, this is the fourth year of drought in Afghanistan and the economic situation there is quite dismal,” she says.

Women—whose oppression under the Taliban gained international attention—have also disproportionately fallen victim to tuberculosis.

Eighty percent of tuberculosis deaths and 70 percent of new cases are among women.

“Women spend a lot of time sequestered indoors. They are married very young, have many children and their nutrition is much worse,” Goldfeld says.

Tuberculosis—while completely curable with antibiotics—requires a strict six-month drug regimen in order to cure the patient. The antibiotics are fairly inexpensive but not available in Afghanistan.

“When you think of health care in our country, and then witness a place where you only need $18 to pay for the drugs to save these people’s lives, that’s a real travesty,” Bock says.

Perhaps more seriously, drug-resistant forms of the disease can emerge from inconsistent treatment and cause untreatable outbreaks.

From Harvard to the Trenches

Heading into Afghanistan, Goldfeld had a battle plan similar to the one she used in her work in another war-torn country—Cambodia.

In the early 1990s, Goldfeld pioneered new ways of giving tuberculosis therapy to refugees on the border of Thailand and Cambodia.

Along with her Cambodian colleague Sok Thim, she founded the Cambodian Health Committee, a tuberculosis treatment program that has successfully cured over 3000 patients to date.

Goldfeld’s program relies on extensive family and community education on the spread and treatment of tuberculosis.

“The thing to remember is that tuberculosis is a curable disease, and we have to do everything we can to provide the medicine and supplies so people can survive,” Goldfeld says.

Each patient enlists a supporter, a friend or family member who agrees to supervise the six-month drug course. Patient, physician and supporter all sign a contract promising to follow the therapy.

“The lesson we learned in Cambodia is that anyone can complete the therapy with the right support,” she says.

Having succeeded in Cambodia, Goldfeld hopes to start a similar treatment program in Afghanistan.

“She’s a real leader not only in research and medicine, but in starting a program that is really a model for the world,” Bock says.

In fact, Bock described Goldfeld’s approach as the medical equivalent of microlending in third world countries.

“Microlending refuses to accept the classical economic assumption that poor people are bad creditors. Anne Goldfeld has refused to accept the classical medical assumption that poor people with tuberculosis should be quarantined and forgotten,” Bock says.

Goldfeld hopes to return to Afghanistan later this spring to begin the treatment program but faces several challenges.

For one, the United Nations’ efforts to begin repatriation of the refugees by this summer will complicate the tuberculosis problem in Afghanistan.

Refugees must continue taking their medicine during the entire six months, even while they return to their homes. To monitor their patients, Goldfeld and the ARC hope to create a computerized tracking system to make sure patients continue to take their medicine even if they are on the move.

Goldfeld also hopes to focus on Afghanistan’s most vulnerable community—women who are disproportionately afflicted with tuberculosis.

One possible solution is to train local female health workers to make home visits to recognize and treat female tuberculosis patients, who often go undiagnosed.

Goldfeld also hopes to bring a high quality microbiology lab to Afghanistan—the ultimate marriage of university research resources and public health service—where locals could be trained to diagnose and treat tuberculosis, as well as test for drug resistance.

Doctoring Without Borders

During her stay in Afghanistan, Goldfeld says she profession, rather than her nationality or gender, became her primary identity.

“I felt no animosity from the Afghan people, either as an American or a woman,” she says.

One of the people she encountered—a woman who had lost her husband, brother, and eldest son in the U.S. bombings—expressed only gratitude to the American doctor who treated her son for burns at the refugee camp.

“One is continually inspired by the strength and humanity of the people you meet,” Goldfeld says. “It’s always a privilege to be in a situation where you can do something positive.”

—Staff writer M. Helene van Wagenberg can be reached at mvan@fas.harvard.edu.