Every day here in Afghanistan seems to yield new and more challenging problems.  They can range from working through a supply issue of nutritional supplements to discussing management of heart failure.  This past month has seen the departure of trusted and loved American and French team members.  It has also ushered in a new French team and for the first time, a team from Greece!  We are lucky to have them and are blessed to have such dynamic and gregarious professionals here.

Care for others and the will surely care for you

As one of the more tenured people here now after 5 1/2 months, I have been discussing the challenges with our new team members.  I believe I have finished my operational perspective on Afghanistan and their culture of caring.  In previous editions I alluded to surrounding oneself with the issues and embracing the challenges they face.  I also spoke about how I view their perspective on caring and how they love each other.  In this edition I plan on discussing my “Afghan Philosophy”.

As you read this you may view me as quite knowledgeable on this subject.  I have had no formal training, nor a degree to suggest I am truly an expert.  But because of our western world view and cultural perspective my lived experience is a valuable indicator for you that I have a perspective you can relate to.

The worldly perspective narrative for you is defined by verifiable facts and your experiences.  In medicine we value “evidence based practice”, because the proof is in the pudding!  Here in Afghanistan truth may be shaped by what a tribal leader says, your husband directs, or a person in a position of influence says is so.  If two people say it, it must be truth.

The power and influence of the local Afghan physician is great. They are trusted and their word is never questioned. Even in the face of insurmountable evidence (we value) the patient and family will follow the directions given by the physician.  Truth is not as important as influence.

This has puzzled me for quite some time.  Why, if I am providing a scientific perspective based on verifiable and reproducible data will the physician continue to select an intervention that is counterproductive? Because their teacher at some point said it was so, and I am not as trusted as their teacher! I find they lie to protect their position.

Over time I have sought counsel from Americans I trust and admire for their wisdom and patriotism. And so a four part approach was born to understand and find success in aiding Afghanistan: People, Process, Tools, Metrics.

Its that simple.  I have been unable to boil down my experiences into an easily discussed and applied philosophy.  And in typical Young fashion it all came together during a run.

People are really the start and finish of this process.  They are why we are here and the most important part of this whole military deployment.  Investment in people is a costly endeavor up front but yields results for a life time.  This is the first part of my observations because with a changed Afghan perspective of their self worth, empowerment, and self esteem I have seen them grow.  I have seen them begin to appreciate their value to the health care system.  I have spent time with them and have become viewed as a trusted friend.  Siaed and his father were my teachers.  Padar (Father) chose my wisdom and opinion over that of the Afghan Physicians.  I am still in awe of how HUGE this was and to have been a part of it here in Afghanistan.  This first part is never complete but will gently slide you into the second.  My lack of understanding this process has not diminished my ability to embrace the second part.

It has taken me 5 1/2 months to gain the status of trusted advisor to some of the staff in the hospital.  Once I had become essential, the process of care began to change unbeknownst to me as, I was looking for it.  I am not speaking of instituting dramatic changes here.  We are speaking about cleaning the floors daily, doing basic nursing assessments (may or may not be charted) and listening to what our wounded soldiers are saying then, delivering solutions.

I have had great success shaping the conversation and situation to show that I value their contributions, I reinforce their importance to the system, and show a desired result.  I have been talking with the housekeeping staff about how their actions directly contribute to decreasing infections on the 4th floor.  I find them doing a good job, praise them in public and surprise them with breakfast and some Chai  tea time with me.  This is a HUGE thing for them.  I don’t drink Chai with patients.  When a General is around I seek them out to say what a great job the housekeepers are doing.  This has proven to be an incredibly successful idea.

To my surprise (or lack their of, the housekeepers are super patriots) 2 weeks ago the 4th floor housekeepers had moved all the patients in a 6-man room into the hallway and were washing the walls and floor.  This was done without my direction, my request, or that of the director of the floor.  They made the decision and acted upon it.  I have never been so proud of the staff as I was that day. All patient rooms are done!

They don’t have a soul, they are a soul. They have a body. Lead with your soul to guide the care of their body.

With the nurses and doctors I take a slightly different approach.  I find a situation or patient that many people are around and all seem to be puzzled over what to do despite my original repeated mentoring.  I ask all the staff to leave except one who I say is to remain as they are the smartest and most capable.  This peaks everyones interest and then the teaching begins.  Does this work all the time?  No.  And I can’t identify when and why it is successful at this point.

I don’t want you to confuse process with policy.  Process is about how we know, do, and be like a contributing member of a health care team.  Policy directs actions within a complex system.  We are years away from instituting policy, for now embracing a simple process that will yield high returns is my vision.

Tools are an essential part of any vocation.  Providers have many tools to perform their job.  For the USA most tools are born from a need that was filled.  In Afghanistan many tools have fallen into disrepair, misuse, and obsolesce due to not being integrated into their system with the same direction we might expect.  But, again this is not the USA this is Afghanistan. We must strive to help them create a functional healthcare delivery system that achieves goals and successes that they define.  Tools that promote safe and efficient care .

This is one of the single biggest tasks this team faces.  New tools are always a welcomed  addition to promote efficient and quality care.  What do we do with technology that requires a sound foundation in medicine that has not been fully developed here?  It is truly not my hospital, can I say no?  We constantly discuss how we can best aid them in planning and implementing a successful system that is owned by the Afghans. They must make it work when I leave.

The idea of measurable changes and successes is called metrics.  In the Navy we look at metrics, in Afghanistan we also want metrics.  How can one measure, in a short amount of time, if a staff member has an increased sense of self worth?  There is probably a way but it is beyond my time (CAPT Hagan is now emailing me to tell me to use PubMed and look it up…. ugh, she is right.  Maybe in the morning).  I view metrics as a final part of the whole care continuum.  When one feels empowered, they find ownership of a process.  Once the process is valued by the individual and is viewed as essential to the system, we look to tools to make the process more efficient.  Finally we arrive a metrics, measuring the success by assigning silos of value to each step.  Here is where we hope to find our Afghan friends’ system in the future.

Shona ba shona, khostan tawanestan

Sholder to sholder, we can, we will!