We have read ‘ Against all odds: a qualitative study of rehabilitation of persons with spinal cord injury in Afghanistan’ by Michael and Roth with interest.1 They have comprehensively addressed a disease, which is often neglected in many of the low resourced developing countries. On the basis of our experience of working with spinal cord injury (SCI) population in this region, which also included Afghans coming to Pakistan for management of SCI, we would like to offer following comments.

  • Pakistan has hosted more than 3 million Afghan refugees for around 25 years during and after the 1980s Afghan war.2 The health care system in Afghanistan is underdeveloped and many Afghans routinely come over to Pakistan seeking medical advice.

  • Establishing a SCI rehab center in Afghanistan might be a distant dream at present, but some practical alternatives are as follows

    • â—‹ Training of the local paramedical staff in the basic management of SCI, including log roll immobilization and transport protocols of a suspected case of SCI. This might prevent aggravation of many of the incomplete SCI, which are fortunate enough to reach a medical facility.

    • â—‹ Afghan orthopedic surgeons who are staying back in the war torn country to serve their people should be engaged in an exchange program with the developed SCI centers of the region and developed countries to enhance their skills and improve their understanding of the SCI management. ISCoS (International Spinal Cord Society) and ASCoN (Asian Spinal Cord Network) can facilitate this exchange. At the least these surgeons should be familiarized with the Standard scoring chart for SCI and the free learning and teaching resources available on the websites of ISCoS (http://www.elearnsci.org/) and American Spinal Injury Association (http://www.asia-spinalinjury.org/elearning/elearning.php).

    • â—‹ In a country with low literacy rate, distributing written patient education material and pamphlets might not help much in getting the message across. Instead posters and pictorial pamphlets depicting the methods of self-catherization and regular position change to prevent pressure ulcers will be more useful.

    • â—‹ In the absence of prehospital care, lack of surgical expertise in the management of SCI and poor financial status of most of the patients, conservative management of SCI cases should be promoted in Afghanistan.

  • Many International NGOs with global experience of managing SCI are providing healthcare services in Afghanistan. A lack of coordination among them results in duplication of efforts, waste of precious resources and inadequate coverage for many areas.

  • In the end, we wonder how trillions of dollars were spent on waging a decade long war on one of the poorest countries in the world, but there is limited funding to establish an SCI center in Afghanistan.