Teleconferencing Medicine

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.

So like no shit, there we were…

Today we went on the PRT (provin­cial recon­struc­tion team) base in Jalal­abad. Lou had arranged the meet­ing. A New York­er was run­ning it. He spoke fast (refresh­ing­ly so, as one’s mind atro­phies from a pre­dom­i­nance of inter­ac­tion with non-native speakers.)

He was excit­ed about a par­tic­u­lar new fund­ing stream from USAID that was meant for off­beat projects that are not being addressed by oth­er large funds. Lou had con­nect­ed a few dots and sug­gest­ed crick­et fields and now the ball is rolling.

Dur­ing the meet­ing I was drown­ing in acronyms. At some point, I request­ed a time out to deacronymi­fy. I think it was around the point that we were told that the pro­pos­al should, of course, address COIN (counter insur­gency) objectives.

Here are some notes from that time-out:  Feel free not to read them!

• PDC (Provin­cial Devel­op­ment Coun­cil) staffed by PC (Provin­cial Coun­cil) who are the vot­ing mem­bers, 19 of which 5 are female.
• ASOP — Afghan Social Out­reach Pro­gram, sub­set of IDLG
• DDA — Dis­trict Devel­op­ment Association
• These are all Shu­ra’s of appoint­ed peo­ples. But the best guys are the rung bel­low them, the CDC — com­mu­ni­ty devel­op­ment coun­cils — “They are like the small town PTA (Par­ent Teacher Asso­ci­a­tions) in Amer­i­ca that know what the local issues are, and they are elected!”
• TWG — tech­ni­cal work­ing group, usu­al­ly the TWG of some sub­ject under some oth­er acronym.
• IDLG — Inde­pen­dent Direc­torate Local Gov­ern­ments (a USAID gov­ern­ment part­ner). They appoint local gov­er­nors, and DDBs (Dis­trict Devel­op­ment Boards)
• ANDS — Afghan Nation­al Devel­op­ment Strategies
• StI­KA — Sta­bil­i­ty in Key Areas. It’s the new LGCD (Local Gov­ern­ment Com­mer­cial Development).
• NSP (Nation­al Sol­i­dar­i­ty Pro­gram) is under the NMRD? WTF?

They did not have a shop at the PRT, but we were able to get some hygien­ic prod­ucts at the MWR (Morale Wel­fare and Recre­ation) bunk.We had lunch at the DFAC. Over lunch, it was men­tioned that USAID is under­staffed in the region. I asked where the bot­tle­neck lies. It turns out that there are more USAID employ­ees hang­ing in Kabul/Bagram ~1200 than are active in the field. And the rea­son is quite an Amer­i­can one. In prac­tice, USAID employ­ees that are part of the PRT have to be phys­i­cal­ly fit to ride with full Army gear in MRAPS. (And that is the only way they are allowed to get around to get their work done.) It’s hot and heavy.

As an Amer­i­can com­pa­ny, USAID has to fol­low the Amer­i­can with Dis­abil­i­ties Act for Hir­ing, which means that they can­not exclude peo­ple based on their lev­el of fit­ness (some­times age or dis­abil­i­ty) for the task at hand. USAID has prob­lems recruit­ing peo­ple that are younger and can get clear­ance. So their pay­roll is full of old guys.

The net result is all the phys­i­cal­ly fit peo­ple (600 of them) are active in the field while Kab­ul is a “geri­atric ward” (1200).

“This is your government.”

***

When you live “out­side the wire”, going the DFAC (Din­ing Facil­i­ty) at the base is kind of like raid­ing your par­en­t’s pantry when you are a poor stu­dent. You fill your pock­ets with gum, soda, cook­ies, cliff bars, etc. Here was our score today:

We focused on gum.  Thanks Uncle Ben!

***

Dave was telling me that when he hung out with the Spe­cial Force guys, all of their sto­ries start­ed with, “So like no shit, there we were…”

So like no shit, there we were on an Amer­i­can base play­ing bas­ket­ball and trash talk­ing in Russ­ian with our Afghan driver/translator Najib, inside an emp­ty swim­ming pool, which was ini­tial­ly built by the Rus­sians when this was their Army base and then used by the Tal­iban as an exe­cu­tion ground. You could see the bul­let scars on ground, and the US sol­diers would cir­cle around us, doing their busi­ness, occa­sion­al­ly recov­er­ing our balls which had bounced out of the pool.

***

And to round out today’s ram­ble is a good one, but you have to click some links. It’s a TAL (This Amer­i­can Life) episode. In the first act you will meet JD (Japan­ese Dude) — aka Mohammed Jawed. He’s the one that took the pho­to of the sheep and boy on the bike (ear­li­er post). Well any­ways, lis­ten to this act, which is like the first 5 min­utes: http://www.thisamericanlife.org/radio-archives/episode/369/poultry-slam-2008

Measure Ma’an

Each be ruled by his own.

Here in Jalal­abad, wood is ruled by a ma’an (my spelling, try­ing to capu­ture the pro­nun­ci­a­tion. Else­where it is spelled mann.)

Most of the heat­ing and cook­ing ener­gy needs in Afghanistan are sup­plied by wood. Along the road you see plen­ty of shacks of the wood deal­ers.  Today we stopped by.  Typ­i­cal­ly kids are chop­ping wood while an old­er beard­ed pro­pri­a­tor (father/uncle) is sip­ping tea and wait­ing for customers.

I noticed our wood was being weighed on a scale, but instead of weights, it was coun­ter­bal­anced by cal­i­brat­ed rocks. The unit of mea­sure is a ma’an, which varies local­ly but approx­i­mates 7 kilos.

A ma’an is the pref­ered unit of mea­sure for wood, and is part of a com­pre­hen­sive unit scale:

Accord­ing to wikipedia the ety­mol­o­gy can be traced to the Hebrew word mana, as in mana from the desert. Every day the wan­der­ing tribe that exit­ed Egypt was allowed to col­lect one Omer of mana. On Fri­day, the col­lec­tion was dou­bled, to pro­vi­sion for Sat­ur­day, the Sab­bath day of rest. An omer is a dry weight of mea­sure, approx­i­mate­ly the vol­ume of 3.5 liters of water. On Fri­day there­fore, the col­lec­tion was 7 vol­u­met­ric liters, which would weigh 7 kg (if water).

To con­tin­ue reach­ing for more con­nec­tions, the ma’an weights were made of stone. An impe­r­i­al stone is 6.35kg, not that far off?!

None of this should be con­fused with a ma’an in Pak­istan. A Paki­ma’an is appar­ent­ly 7 times an Afghan ma’an.

Not every­thing is mea­sured using this scale. If for exam­ple you were buy­ing opi­um, then the stan­dard mea­sure is a “kar­tus” defined as the weight of a AK47 bul­let cas­ing, a sen­si­ble stan­dard from those at hand.

Shoes

Behold a typ­i­cal Afghan shoe.

It’s a dress shoe, because that’s the pre­ferred style. And it’s bent in the back because they wear them like slip ons. This is con­ve­nient. Afghans take them on and off so many times a day. They take them off to pray 5 times a day. They take them off when­ev­er they enter some­ones house for tea, etc. etc. And this is prob­a­bly true across most of Cen­tral Asia and many oth­er coun­tries in the “rug belt”.

What I don’t under­stand, is why no one has seized on this huge mar­ket oppor­tu­ni­ty of mak­ing a fan­cy dress shoe, with­out a back, a dress shoe nat­ur­al slip on? (Maybe some­one has, and this is your oppor­tu­ni­ty to mar­ket their wares in the comments.)

Anoth­er inter­est­ing con­se­quence of this, is that there is so much more work for shoe shin­ers. When you take off your shoes in the restau­rant, they walk up and make their offers.

This is a much more nat­ur­al way to do this than what I have seen in the West. I just could­n’t ever imag­ine myself sit­ting down to have some­one kneel in front of me to shine my shoes, while I made myself look busy with a news­pa­per. To bad, I have noth­ing to shine here. Can you guess why?

I got some army boots from the Bush Mar­ket the oth­er day, and while I smelled weed when we walked into the shop, I did­n’t expect the shop­keep­er to take a mini break to toke on a apple core bong in the process:

Coming to Terms

And there’s more where these came from…

Kabul to Jalalabad

The ride from Kab­ul to Jalal­abad was long and adventurous.

I saw a dog being killed in Kab­ul. They are con­sid­ered pests here.

Most of our dri­ve time was spent sit­ting in traf­fic on the windy seg­ment of the Kab­ul Riv­er Gorge (also called Tan­gi Gharu).

Part of the rea­son for the bad traf­fic is that peo­ple tend to dri­ve on both sides of the road in both direc­tions. At first it seems like a good idea, you get a lit­tle bit ahead of your neigh­bor. But local opti­miza­tion can some­times lead to glob­al cat­a­stro­phes. Such deci­sions cre­at­ed grid­locked jen­ga puz­zles on nar­row roads with pre­car­i­ous drop offs and small mar­gins for error. Each one took hours to resolve.

Had we left much ear­li­er in the morn­ing (say 6am) we would­n’t have expe­ri­enced this traf­fic. And so we sat in the car, or got our to stretch our legs, or to take pho­tographs of war debris from var­i­ous wars, such as this Russ­ian tank:

When­ev­er we’d show our faces, a crowd would appear. The younger ones talked to us. Some­times they asked for “ener­gy” = soft drinks.

I met a boy named Pamir who is studing law, on the right. He’s gonna be a bureau­crat some day. On his stu­dent card, you could see his blood type.

Jin­gle Trucks from Park­istan con­sti­tute a large frac­tion of the traffic:

Out of the gorge we were out in broad open val­ley swept by opaque dust storms, bend­ing trees horizontally.

The road had warn away in parts, and you have to be ready to stop abrupt­ly when you spot a pot hole. This caused our acci­dent. A truck in front of us stopped. We stopped right behind it, and many cars stopped on our bumper behind us… So far so good. But the truck in front start­ed back­ing up. We honked. It did­n’t care. It ate half our hood before it final­ly stopped.

Thank­ful­ly, its clear­ance was high enough that the dam­age was only cos­met­ic. Since there is no insur­ance and no pro­to­col for how to resolve acci­dents oth­er than by talk­ing. Our dri­ver (on the right) got out and start­ed a long nego­ti­a­tion direct­ly on the high­way. (Truck dri­ver is on the left.)

This is one of the main rea­sons why for­eign­ers are dis­cour­aged from dri­ving. All of the NGOs and even the secu­ri­ty com­pa­nies now hire local dri­vers. This is the kind of advice we get: if you hit some­one, get the hell out of there. If you stick around, you will get clubbed. (And if you see some­one dead/wounded, look out for boo­by traps. This one applies not only while driving.)

One amaz­ing thing about Afghanistan is the jusx­ta­po­si­tion of the past and the future, and how one caus­es the oth­er.  There is no postal ser­vice, for exam­ple.  You have to rely on email.

There will prob­a­bly nev­er be a wired tele­phone net­work here, but every­one has a cell­phone. Cell­phone tow­ers (when not pow­ered by gen­er­a­tors) are pow­ered by solar.

We did see con­struc­tion crews lay­ing fiber optics cable along the high­way. Sad­ly, I missed the pho­to op. Maybe Lou or Todd got it?

Much of the coun­try’s hydro­elec­tric facil­i­ties are locat­ed along this stretch of riv­er, so the fact that the Kab­ul riv­er is but a stream, presents a problem.

Approach­ing Jalal­abad, we pass the Darun­ta Dam and afte­wards is Nan­ga­har Uni­ver­si­ty whose ini­tial build­ings were used to house the Sovi­et engi­neers that built and oper­at­ed the Darun­ta Dam.

Right before you breach the perim­iter of Jalal­abad city prop­er, take a left down Awe­some Tod­d’s road (see Open Street Maps).

Wel­come to the Taj. This has become our home (Lang­ton Annex 😉 More about the Taj and its occu­pants in anoth­er post.

For now, a teaser:

This is part of the longer nar­ra­tive blog series, that start­ed with What is Nor­mal any­way? I will try to have this sub-series fol­low a lin­er nar­ra­tive, while the gen­er­al post stream will jump around.

Nangahar Public Hospital

The first time we came to the hos­pi­tal, the staff apol­o­gized pro­fuse­ly for not being able to host us. They were deal­ing with the wound­ed of a sui­cide bomb­ing inci­dent in the dis­trict. There was one casu­al­ty. Five peo­ple were in the OR. And they were embar­rassed in front of us, that such things hap­pen in their coun­try. We left, and came back yesterday.

Nan­ga­har Pub­lic Hos­pi­tal (NPH) is a Region­al Post-Grad­u­ate Teach­ing Hos­pi­tal for the East­ern Region of Afghanistan. The East­ern Region cov­ers the provices of Kunar, Nan­ga­har, and Lagh­man. But in prac­tice it also cov­ers the provinces of Log­ar and Kapisa, and the dis­trict of Siro­bi (which tech­ni­cal­ly belongs to Kab­ul Region).

22 clin­ics from the East­ern Region trans­fer patients to NPH by ambu­lance. The hos­pi­tal does not have an Emer­gency Response Ambu­lance team. Three dis­trict hos­pi­tals of Kama, Ghani­ki and Khugiani also refer patients to the NPH.

Loca­tion. The hos­pi­tal is locat­ed in the city of Jalal­abad, halfway between Peshawar and Kab­ul, on the main high­way link­ing the two. This high­way is the main transport/supply line between Pak­istan and Afghanistan. The bor­der check­point, called Torkam Gate, is a half hour to the East and is the entrance to the Khy­ber Pass. The stretch of high­way west to Kab­ul is con­sid­ered the most dan­ger­ous road in the world by the NYT. It is dan­ger­ous because of acci­dents. And often, because of acci­dents, traf­fic on the nar­row road comes to a com­plete stop. NPH sees 600 patients from car acci­dents each month. Some patients pre­fer to be referred to NPH rather than hos­pi­tals in Kab­ul because, if the issue is suf­fi­cient­ly crit­i­cal, it is a much clos­er dri­ve to Peshawar, Pak­istan where there are hos­pi­tals bet­ter than any­thing in Afghanistan.

The hos­pi­tal has 10 depart­ments, which all train post-grad­u­ate spe­cial­ists: Inter­nal Med­i­cine (Med­ical Ward), TB, Infec­tious Dis­ease, Pedi­atric, Gen­er­al Surgery, Ortho­pe­dic, OBGYN, ENT (Ear, Nose and Throat), Opthamol­o­gy, Neu­ropsy­chi­atric (opened this year.)

A post grad­u­ate med­ical spe­cial­ist is some­one who has grad­u­at­ed a sev­en year med­ical pro­gram, CONQUER EXAMINATION, like SAT that deter­mines which Fac­ul­ty at which Uni­ver­si­ty you can attend: The order of RANK based admis­sion by fac­ul­ty fol­lows: Med­ical, Engi­neer­ing, Eco­nom­ics, Law, Agri­cul­ture, Com­put­er Sci­ence, Lit­er­a­ture, etc. So to get to med­ical school in the first place, they need­ed top marks. — Accord­ing to Ahmed “Zia” Ahme­di Here Afghan stu­dents vent about high­er edu­ca­tion on Face­book.served a 2 year prac­ti­cal at a region­al clin­ic, and received high marks at a cen­tral exam­i­na­tion in Kab­ul. Based on their grades and spe­cial­ty of inter­est, they are sent to post-grad­u­ate train­ing hos­pi­tals around the coun­try. Most spe­cial­ists train for 3 years, OBGYN is 4 years, and surgery is 5 years.

Accord­ing to Alhaj, Alhaj means that he has per­formed sev­er­al pil­grim­ages to Mec­ca.  If it were just one, he would be mere­ly Haji. Prof. Moham­mad Ismail “Alam”, Chief of Med­ical Ward, there are 30 spe­cial­ists being trained in the inter­nal med­i­cine depart­ment now, and 15 fac­ul­ty. (By con­trast, there are 3 trainees in the neu­ropsy­chi­atric depart­ment, hav­ing start­ed just this year.) The Med­ical Ward has 15 beds in the ICU/CCU. 8 for women and 7 for men. There are 12 nurs­es, 6 female and 6 male, and 1 head nurse. In the ICU and CCU both men and women take care of patients of both gen­ers. There are also spe­cial wards where female nurs­es take care of female patients.

Prof. Alam first stud­ied to be a doc­tor in the 1970s from an Amer­i­can NGO called CARE/Medico. CARE/Medico in Afghanistan — I can­not under­stand how a writer of Carl Edgar Law’s cal­i­bre could have pos­si­bly researched health care in Afghanistan and, more par­tic­u­lar­ly, med­ical teach­ing there over the past two decades (Can Med Assoc J 1983; 128: 186–190) with­out dis­cov­er­ing the work of the med­ical ser­vice arm of CARE known as CARE/Medico.From 1963 to its dis­so­lu­tion in 1979 CARE/Medico car­ried out a 3‑year res­i­den­cy pro­gram for recent­ly grad­u­at­ed Afghan doc­tors from the Uni­ver­si­ty of Kab­ul. This pro­gram’s nucle­us was a per­ma­nent team — includ­ing a Cana­di­anstaffed lab­o­ra­to­ry in Avi­cen­na Hos­pi­tal, Kab­ul — sup­ple­ment­ed month­ly by vol­un­teer spe­cial­ists from the West, main­ly Cana­da and the Unit­ed States. It was Afghanistan’s only con­tin­u­ous med­ical teach­ing link with the West­ern World.Dur­ing its 15-year exis­tence (ter­mi­nat­ed by the Russ­ian occu­pa­tion of the coun­try, like the Man­age­ment Sci­ences for Health pro­gram) this teach­ing course was, in effect, a high-grade res­i­den­cy pro­gram in med­i­cine, surgery and gyne­col­o­gy.Prob­a­bly more than 100 young Afghan doc­tors became pro­fi­cient in West­ern med­ical and sur­gi­cal teach­ing and tech­niques. There was also a nurse’s train­ing pro­gram. So thor­ough was it that short­ly after my return from Kab­ul in 1968 (hav­ing served in the CARE/Medico pro­gram there as a teacher) I met one of my stu­dents, who had just qual­i­fied as a sec­ond-year res­i­dent at St. Paul’s Hos­pi­tal, Saska­toon.This may not seem remark­able unless you remem­ber (as men­tioned in the CMAJ arti­cle) that the Uni­ver­si­ty of Kab­ul’s med­ical school taught “archa­ic” med­i­cine in French that was simul­ta­ne­ous­ly trans­lat­ed into a Far­si dialect, which is pret­ty well devoid of med­ical equiv­a­lents.I feel that Mr. Law’s arti­cle was infor­ma­tive — but only on a small seg­ment of the sub­ject. Canada’s con­tri­bu­tion in exper­tise and man­pow­er (doc­tors, nurs­es and lab­o­ra­to­ry tech­ni­cians) to this Afghanistan pro­gram was out­stand­ing and should be duly record­ed.FRANK MACINNIS, MD, FRCP©, FACP; Clin­i­cal direc­tor; Depart­ment of Psy­chogeri­atrics; Alber­ta Hos­pi­tal; Edmon­ton, Alta. (source: PubMed) He fond­ly remem­bers Dr. Mobri (first name and not sure about spelling) who taught him, and won­ders if he can get in touch with him now. The Amer­i­can staff left the CARE/MEDICO inter­nal med­i­cine train­ing clin­ic when the Rus­sians came, and Prof. Alam stayed there for 13 years (whole time of the Russ­ian occu­pa­tion) lead­ing the clin­ic. He said that the Rus­sians kicked out the Amer­i­cans and treat­ed the CARE/MEDICO trainees with scep­ti­cism, accus­ing “Alam” of being a CIA agent. “When the Rus­sians left and Mujuhadeen came to pow­er and there was unrest in Kab­ul (ear­ly 90s) I left on a fel­low­ship to India. And when I returned a few years lat­er to the Tal­iban, I trans­fered to Nan­ga­har Pub­lic Hos­pi­tal and have been here ever since.”

Most hos­pi­tal build­ings were ini­tial­ly built by Rus­sians. For a while, the Red Cross of New Zeland sup­port­ed the surgery depart­ments. Now the whole hos­pi­tal is man­aged by Health­NET TPO, an NGO based in Hol­land, and fund­ed by the Euro­pean Com­mis­sion. The hos­pi­tal is owned by the Gov­ern­ment, but Health­NET man­ages it and pays for all patient ser­vices as well as all 545 staff of the hos­pi­tal from Secu­ri­ty Guards (whose pay starts at 5000 Afs = 100$ per month) to Nurs­es (7.5–10k Afs=150–200$/month) to Doc­tors (12–20k Afs=220–400$/month) to Admin­is­tra­tors (~15k Afs = ~300$/month).

Ahmed “Zia” Ahme­di is the hos­pi­tal admin­is­tra­tor employed by Health­NET TPO. He is 28, ener­getic, and speaks almost per­fect Eng­lish, which he learnt in Pak­istan, where he spent the first 22 years of his life. He sports an iPhone 3GS which rings non-stop. He jokes, “I am like the tele­phone switch board.” He moved to Kab­ul six years ago to work for the UN, then switched to work for a US State Depart­ment Jus­tice Sup­port Ini­tia­tive, and then as an admin­is­tra­tor for the Inter­na­tion­al Med­ical Corps. But he likes his cur­rent job at the hos­pi­tal most, because he sees the peo­ple he helps.

Zia says that the biggest prob­lems with hos­pi­tal are social. Patients fight with doc­tors, neglect health codes, and barge into Oper­at­ing rooms dur­ing surgery. “They are unfa­mil­iar with hos­pi­tal conduct.”

Soccer with the Boys

The cook scored 3 goals. The mechan­ic Sadik stayed in goal. The guard Metin scored 7. I scored 9.

Introducing Hameed!

We kick off the New Year with a new author on our site. Meet Hameed Tasal.

Here Hameed is align­ing the Satel­lite receiv­er dish atop the Taj. See the ear­phones? He’s not rock­ing out to blas­phe­mous tunes, but lis­ten­ing to the diag­nos­tic pitch that tells him if the info can­non is hit­ting the target.

And he’s no stranger to big name pub­li­ca­tions (such as Jalala­good) hav­ing been inter­viewed for the Boston Her­ald this April. Worth a read.

Happy New Year!

Thanks to Anselm for com­ing up with it, we have a new tagline:

Adven­tures in Khy­ber­space!

Get it? We’re focused on bring­ing tech­nol­o­gy to the Khy­ber Pass. Just a few days ago, we took a dri­ve to it’s West­ern Edge, the Torkham Gate.

This street scene brought to you by JD, a friend of the TAJ: