Tuesday was one of my most rewarding days in Afghanistan. I witnessed something undeniably and irreversibly positive.
In the morning an ambulance came to pick Dr. Pete and me up from the Taj. We crammed along with the driver in front, while 5 female OBGYN doctors and a male ward director sat in the back, occupying one bench and the patient cot. I’ve ridden in the back of this ambulance before and know that the cot slides around and the whole setup can’t really accommodate more than 3 comfortably. But the back also contained a bunch of endoscopy equipment, which I had taken out of the hospital (where it had previously sat for 7 years unused, after USAID proudly donated it but forgot to teach anyone how to use it, or even bother to figure out whether sensitive expensive equipment from America can be plugged into the unpredictable current coming out of their wall sockets.)
Then again, I have also ridden on the lap of an older bearded Afghan stranger in a Toyota Corolla station wagon taxi where we were 11 all together and 3 women sat in the trunk. Hameed, who was my companion on this adventure, tried to pass me off for an Uzbek who didn’t know the local language. That cover lasted for about 3 seconds until one of the geezers started talking to me in Uzbek, and then laughed that I didn’t know my own language. Then Hameed claimed I was mute, for lack of anything else to say. That excuse lasted for as long as I didn’t speak (3 seconds) since he had failed to warn me of his intentions. They all laughed and the guy told me ‘kine kana’ for sit dude and guided me onto his lap.
Ambulances are not used in the same way in Afghanistan. They may sometimes transport a patient from a rural clinic to the main hospital, but mostly they are for off-label uses. The driver is crazy even by Afghan standards. Usually he blares his siren, verves in traffic, as if he were born to be a race cum bumper car driver, playing perpetual chicken on the drag. Today he managed to keep himself mostly in check, probably because of the female doctors.
Today, we were heading to the ILC (the Internet Learning Center) at Nangahar University for the first ever teleconference between the doctors of Afghanistan and Pakistan, and I was a little bit anxious.
Culturally, we men are not allowed to speak to the female doctors (or females in general, other than the ones we brought along with us). We cannot look them in the eyes. We follow this protocol because we have been told that doing otherwise would make them feel uncomfortable. Instead, our conversation flows through a respected Afghan intermediary. That was the role of the male doctor who is their ward director.
But, you see, sometimes, and in our situation in particular, it is useful to talk, such as, when you need to assess their needs for a particular type of training. Do they speak English? How well? Would an English speaking specialist suffice? Should the trainer speak Pashto? Is translation only necessary for the finer points?
We got off to a bad start. We were having internet quality of service problems. The conference quality was jittery to the point of annoying. We finally hacked together a solution, using the video feed from the polycom teleconferencing unit while routing the audio through Skype. At last it was working.
Teleconferencing is a visual medium. When we first fired up the equipment and their faces popped up on the screen, I saw the doctors play out their instinct to bring their veil to their faces and hide from public view. We disabled the window-inside-the-window on the projected screen that showed us what the doctors in Pakistan were seeing. You can hide behind the voice, but not behind a camera; but you can think that you are hidden when the camera isn’t revealing what it sees.
When selecting a location for the conference, we considered several places with passable internet. In the past a conference had been scheduled at the Taj, but the women did not show up because of cultural issues stemming from the fact that it is known as a Westerner enclave. So now we were on neutral turf at Nangahar University, (having transported them 10 miles to an internet center that was built by the Rotary Club and to internet that was provided by NATO.)
The female doctors sat in the front row and the men sat behind them.
Dr. Pete’s main gig is running a company that sets up telemedicine capabilities in various hospitals and field clinics around the world. Though his working relationship with Holy Family Hospital in Pakistan, Pete got a female OBGYN doctor ultrasound specialist and a female Pashto translator to teach a class on the proper use of an ultrasound.
I was playing general internet and audiovisual tech in the equation.
It started out as a boring lecture. The lecturer spoke, the slides advanced. For me the material was new and therefore interesting. I also had the second occupation of observing the entirety of what was going on. But the intended audience sat silent and seemed bored.
Were female doctors reluctant to ask questions? If so, why? Were they shy? Was it old hat and boring? Were we the condescending foreigners that assumed they were merely playing doctor until they met us and wanted to teach them a thing or two?
Pete was doing a good job breaking the ice, asking “dumb questions”, and managing the flow.
And then, about an hour into the lecture, a new voice piped up. She spoke quietly and was further away from the microphone so it was harder to hear. I climbed around a maze of wires (from the polycom, the projector, the speaker system, the laptop and attached microphone) and brought the microphone nearer. The female doctors laughed at my parkour moves to maneuver the laptop and not snag any wires. We were beginning to win them over.
They asked two or three questions in all. We ran around behind the scenes, printing new handouts that the Pakistani doctors sent over in response to the questions.
Two hours after it started, the class was over. By way of effective classes, this was a failure. Very little new information was transfered per unit time.
I positioned myself at the back of the classroom next to the male ward director who has been typing away smartly at this laptop and chatting on his cellphone during the lecture. He had a long white beard, designer glasses, and a traditional white cap. I told him that we understand that the class wasn’t perfect, but that we considered this a first test. We would also like to become better and improve the classes and to do this we needed open criticism from the doctors themselves. He walked to the front of the room and translated what I said to the doctors.
And then something unexpected happened. They turned and started to speak to us directly. Or, under these circumstances, I can be forgiven for erring on the side of calling it directly. They expressed their needs. They expressed satisfaction at today’s meeting.
At first their remarks were ventured in the void, not addressed to anyone in particular. But then we (also) started to feel comfortable to engage the individuals, responding to individual comments and weaving a common conversational thread. It was a true dialog. We took notes: they wanted large, high resolution actual ultrasound images, case studies, examples of normal and abnormal cases. (They said that they didn’t know what normal was supposed to be!) They wanted to be doctors playing diagnose-this-patient while staring at the same raw image. They didn’t need a basic theoretical review. They had the books and studied them. They wanted the doctors in Pakistan to show their images, and they wanted to bring their own troubled cases to discuss.
(Please “Please forgive the poor audio quality and lack of editing, but you can hear the banalities of the moment for yourself.” forgive the poor audio quality and lack of editing, but you can hear the banalities of the moment for yourself.)
The women ranged in age from the 30s to their 50s and in this conversation I saw within them articulate doctors who cared about their patients and wanted to become better stewards of their health, but also I saw (forgive me Allah for saying this) youthful excited chattering girls.
Pete pointed out that doctors from developed countries have a lot to learn from Afghanistan. Since it takes so long for people to get themselves to a hospital, patients present advanced stage pathologies. Abnormalities are so common that you almost have to redefine normal. He told me that when he spent a day at another ultrasound clinic in Jalalabad, he was blown away at the presentation of unusual in every case. Each would be a case study in America. You just don’t see that kind of stuff as a doctor. More cases in one day than he has seen in all his clinical rotations.
We learned a lot from this session, simple banal things.
We learned not to ask, but to just give. You endlessly wallow in self-censoring cultural sensitivity orbits asking whether you can communicate with the doctors directly, but then again, you can just do it. Don’t ask can we have your emails. Just give a hand out with your own, with the Pakistani doctors emails, the coordinators, etc. Add a note describing what role each person plays and put the ball in their court.
At the end Qahar, a friend with whom we collaborate with on various internet projects, walked into the room. On their way out, the female doctors surrounded him. They told me that he is their computer teacher and their English teacher too. It was clear that they appreciated him.
And that appreciation also cautiously reflected on us. They started to trust us that we actually cared and weren’t there to merely wave an illusory magic wand in the form of high-minded advice and grandiose consultation based on “The way we do it in America …
Of course, it is dishonest to end on such a positive note. A couple days later, we went for a second victory. The head doctor of the hospital where the women worked was supposed to have a one on one planning meeting with the chief doctor from Pakistan, to plan future training session for doctors from other departments. It was the third attempt to schedule such a meeting.
The time was set on both sides, the venue prepared, various parties were involved. And then, he didn’t show up.
I was sad and it showed when I talked to our friend at the ILC. And he tried to console my by saying, “We are used to this. We plan, we talk, and then when it comes time, it doesn’t work out. That’s normal.”
It’s a big challenge to stop being used to failure. It’s a big challenge to redefine normal.