Rebuilding means something used to be there

I've been in Afghanistan for two weeks and only now am I beginning to get an idea of what my job will be. Unlike most people who arrived with me, I was not a direct replacement for a departing officer. That means I had no turnover brief or orientation to my job responsibilities or clear explanation of exactly what I'm supposed to complete or supervise or promote for the next twelve months. I'm new and my position is new, and that can be advantageous, or disastrous. As an example, as a staff officer, I am considered available to fill space on any "advisory board" or "working group" on base that needs representation from medical personnel. My military experience such groups has been that they advise very little and work even less. It's hard to maintain consciousness when your day is enveloped by their meetings, and the incessant dozing they induce plays havoc with my ability to sleep through the night. So I'm trying to create a few specific duties and projects for myself that might keep me occupied and focused during the day. I might even be able to assist the Afghan Army in the development of its medical system.

The US Navy has teams of physicians, nurses, hospital administrators and other health professionals "embedded" at different Afghan Army and Police hospitals and clinics throughout the country. These teams typically live on the grounds of these facilities, and they can probably count on one hand how many times they leave the premises during their 6-12 month deployment. In Kabul, at a base small by American standards but pretty large relative to the hospital grounds in Mazir-e-Sharif or Herat, sit me and other administrative and leadership staff who work to direct and support the embedded teams. "Direct" might mean that we implement through the embedded teams a trauma care plan devised by the Surgeon General of the Afghan Army. "Support" might mean that we procure a means of refrigeration for vaccine doses spoiling in the heat of Kandahar.

My first task has been to formulate a monthly reporting scheme for the embedded teams in order to better track their progress in mentoring the Afghans to provide better care for soldiers and their families. So far, reports from the regional hospitals have varied from "emergency room here is really coming into its own and better caring for patients" to "staff still loathe to wash hands before entering the operating room" and "surgeons no longer using the same set of instruments on two different cases simultaneously." Much of the mentoring here is very basic. The facilities are called hospitals, but an American would hardly recognize the organization and services provided within. A significant percentage of any hospital staff is likely illiterate, and that makes record-keeping a bit difficult. Many of the nurses have had no formal education. A physician may or may not have attended medical school classes or passed any formal licensing or certification exam.

They're not dishonest. For the past several decades, Afghanistan has not been able to offer most citizens the opportunity for a good primary and secondary school education, let alone quality medical training. No uniform, objective training standards seem to exist for these positions. An Afghan ophthalmologist told me that after his medical school training, he passed both the internal medicine and surgical exams, and he decided to practice ophthalmology. I'll admit that a language barrier was present, but I could not elicit from him any recount of focused ophthalmic training he received. It appears that local surgeons simply select the specialty that interests them most. A colleague told me of meeting the Chief of Surgery at a provincial hospital who pleaded for a different professional post as he trained in internal medicine, and had not even attended a surgical case as a medical student.

US military medical professionals are working for improvements in Afghan military healthcare as our efforts are part of a larger strategy to improve Afghanistan's internal security by reinforcing and expanding the national army and police force. American medical personnel are engaging the Afghan healthcare system at the clinic and hospital level. Progress is often elusive and usually precarious. If an Afghan hospital represents the pinnacle of healthcare here, the illustrious apex of a pyramid, then any embellishments to its facade stand in danger of collapsing groundward as the elements of a solid structural base necessary for a society to sustain advanced care -- a high literacy rate, adequate economic resources, sustained electricity -- are usually lacking. Afghanistan is a development project at every level. Few geographic and societal sectors in Afghanistan are being "rebuilt" as they have never existed. Progress should be measured in small increments as the task is monumental.

There are professional assets here: Afghanistan has dedicated, intelligent and sometimes well-trained medical professionals, although not nearly as many as needed. The US is attempting to mentor some of these people in hope that a partnership will result in better care for all Afghans, a necessary element for the country if Afghanistan is to be a stable country that doesn't pose a threat to America. That's the US military's goal for Afghanistan, our current "end-point." With respect to Afghan medical care, the project will be decades long. The medical education tract begins with a basic education and then continues as prospective healthcare professionals progress through a training sequence that takes many years. The US has been in Afghanistan intermittently for only seven.