On the last day of the course, I merged the last case review session with Abdullah’s classroom session on biostatistics. An additional group of residents approached me to ask if we could run a second course for more residents. We planned ahead with their schedule in mind and arranged to start it on Saturday after the off day on Friday. More people able to use the probe meant more potential for our project to directly impact patients.

That night after a long day and a big meal, Tayseer, Abdullah and I sat outside in the courtyard of the hotel. We were also joined by Dr. Suhail, an oncologic surgeon leading our surgical division and fellow humanitarian, who I first met on a different project in Jordan. As we sat, my small Bluetooth speaker filled the background silence. Tayseer, ever pensive, took a slow drag from his cigarette as he looked up at the stars.

‘You know guys, every time I come on these missions, I ask myself how we can make a bigger impact than we are making,’ he said.

The perennial discussion repeats itself.

‘Is it possible to come here and not ask yourself that?’ I answered.

What followed was the most typical conversation you will ever hear between aid workers. This is the subject of debate within humanitarian think tanks all over the world. When your resources are finite and the obstacles so nuanced, what is the best way to maximize the impact of every dollar? In these journals, I have tried to draw from my experience to inform that discussion. I really think of humanitarian aid falling into two different camps that are sometimes but not always mutually exclusive: development versus aid.

When it comes to development, stable governance and a functional economy are the backbone of everything. If you live in an active conflict zone, or a place with unstable governance and no economy, forget education, innovation, growth, or healthcare development, it just can’t happen. To me, the term humanitarian crisis implies sudden periods of destabilization when really the opposite is true. A crisis occurs when you add an acute insult (war, famine, natural disaster, epidemic) to an already injured system with no bandwidth to respond. For this reason, there are some that argue that humanitarian work really should be developmental, because otherwise we only paper cracks without addressing the ailing networks that eventually decompensate to produce episodes of crisis.

So, if we’re going to target development as the end goal of a humanitarian project, the question then becomes where to target that development.

‘I ask myself this Tayseer,’ I said. ‘If I had to choose one branch of social structures and one only to improve conditions, which one would I choose? Let’s say health, versus education, versus governance, versus the economy, I would probably say health is the lowest on that list. Good health will never bring the rest. Governance, on the other hand, would organically produce improvements in all the others, maybe the same with economy, or education. But here I am treating patients and training doctors, when really I ask myself if this is the least effective way to go about it.’

‘I think of it in terms of what I can provide that nobody else can,’ Suhail said, talking with his hands. ‘I am an expert in this type of surgery, not many others can provide this particular skill from a training perspective that I can.’

‘That is true,’ I answered. ‘But say if instead of coming here, taking those five days off in the OR, what if you just worked all those hours in the US and then just sent that entire sum of money here instead? For investment in whatever, microlending, small businesses, food supplies, you get what I mean. Would that actually make a bigger impact on more people?’

‘Probably would,’ Abdullah answered. ‘Say we used that money to build a factory for hand sanitizer and create jobs in the process.’

‘These are all good points,’ Tayseer continued. ‘For us, it is hard because we come here and see so many different areas of need. I think when we come on these short term missions one of our biggest goals should be to stick to our mission objectives, otherwise we go crazy. I don’t know if it is our responsibility to overhaul these systems.’

This was maybe the truest statement of all. I don’t know if it is our place to arrive on day 6 of our 12 day mission and take responsibility for turning over entire systems. Staying narrow and leaving something behind is likely the biggest impact I can make on a first venture like this. With some demonstration that we can bring good change, partnership begins to form with local structures, and eventually maybe we get to a place where the system itself invites us to play a role in its remodeling.

Development aside however, aid still has its place. Yes, development is the key to true improvement, but we still have entire populations of people suffering in the face of acute crises that need help. We may maximize our impact algorithmically with development, but people in crisis still need aid. So then the question becomes how to deliver aid responsibly, or in such a fashion that still does right by the ultimate humanitarian goal of teaching how to fish instead of giving fish.

I don’t claim to have any of these answers, whoever does is either a liar or takes themselves too seriously. What I can say though is that at least there are men and women sitting under the stars somewhere after dark losing sleep over such dilemmas.

So long as that exists in the world, I will never lose hope, no matter how grim things seem.

And things were about to get pretty grim.

Earlier in the week, Tayseer, Khalid, and Eyad had gone to visit a local orphanage in the city. That night, the second or third of our mission, Eyad came to our evening debrief looking like he had seen a ghost.

‘Today was rough,’ he said.

Rough because of how disturbing their experience had been.

‘These were like the forgotten of the forgotten,’ he said. ‘Behind this huge wall, right in the city just like any other wall, the gates open and you enter what looks like a concentration camp. The kids thought we were police coming to take them to jail and all immediately started crying. They sleep on padded mats on the floor. There’s feces in the classrooms; the smell is unbearable. In one room they keep the disabled children and they just lay there on the ground. The kids are covered in insect bites, malnourished. It was horrible. We have to go back.’

So go back we did. After hearing of the conditions, we opted to skip our day off on Friday in exchange for a return visit to the orphanage. The night before, Adel, Abdullah and I compiled a list of preventative medicines to give on our one off visit – vitamin D, B12, anti-parasitics, scabies treatments, and the like. It was a venture that took us to three different pharmacies as we bought them all out of their stock for the 400ish kids at the orphanage.

Arriving through the gates, I understood what Eyad had meant. Tall barbed-wired cement walls with an observation tower in the corner overlooked a dirt field. On the far end from the gate was the orphanage.

Just outside the entrance, we set up tables and got all of our medicines ready in an assembly line-formation. We agreed on a process by which the kids would take a dose of all the vitamins and anti-parasitics before having a nutritional screening and skin check with myself, Abdullah, or Adel. Any obvious infectious rashes would result in a treatment plan and then the kids would go back out into the field to play or into their canteen for lunch. The orphanage staff, our local partners from YAAR, and even our personal security guys helped in the process of ushering kids or helping them open water bottles to take their medicines.

Over the next three hours, I saw kids ranging from age five to adults in their early twenties. In a sense, it reminded me of our health screening in Uganda, only slightly different. The difference was that the kids in Uganda were all smiles, and these ones in-front of me were not.

It was hard.

Many of the kids were wearing big winter coats, the same ones provided by Khalid and Eyad when they came to the orphanage earlier in the week. It made me realize that there was a good chance that these articles were all the clothing they owned.

One by one, I would take the kids and make sure they had swallowed all the medicines. Then, I would motion for them to raise their shirts and pull up their sleeves. Out of 360 boys I saw, probably around two thirds of them had obvious signs of scabies, a microscopic dust mite that burrows in the skin and bites, causing an itchy rash. I saw some ranging from not too bad, to entire abdomens and chests covered in scabies bites. I saw many with bites all over the hands and arms too. After a while, I noticed that in the ones that didn’t look so bad, I couldn’t get under the waist of their pants to check the lowest portions of their abdomens. The drawstrings were all tied paralyzingly tight, to the point that when finally working them undone, I’d find friction burns across their waists, raw and sore. After I found enough of them I came to a realization as to why. No, I thought to myself, it can’t be. Finally I got one that was around 16.

‘Can you ask him why his pants are so incredibly tight?’ I said to the orphanage teacher who was standing behind me helping out.

They exchanged words.

‘He says that when they tie their pants so tight that it hurts, the bugs can’t crawl up from their legs,’ he told me.

Imagine that. My heart broke.

Not long after I saw a 22 year old. He had the worst manifestation of scabies I had ever seen. His skin was entirely covered in lesions, almost like small-pox, including swollen hands. He wouldn’t bring his gaze up to meet mine.

Yusef was close by, handing out medicines.

‘Yusef,’ I would go on to tell him later. ‘That guy was your age. The only difference between the two of you is that he was born here and you in Chicago.’

About an hour into our screening I became emotional, gesturing only with my hands out of fear that my voice would quiver if I spoke aloud. Eyad was right, I was looking at the hopeless of the hopeless, the true forgotten souls of Afghanistan. How many unvaccinated, undernourished, sleeping in cold squalor for years? How many times in the past year had any of these boys been shown love?

I looked around and saw all our staff members were wearing surgical masks, and anyone handling meds or touching the kids had gloves. I decided I had enough. I ditched my surgical mask, respiratory pathogens and foul smells be damned. I wanted to greet the kids with a smile. I had to.

‘Salem Aleykum!’ I said to the next kid in line. Waving him towards me, I raised my hand for a high five. He didn’t seem to get it. I high-fived myself and gestured for him to do the same. He cocked his arm back and slapped one on me.

Something, I thought.

After completing the screening and med giveaway, we pumped up a few soccer balls. In the glow of the Afghan sun with a ball and two goals, half a dozen men and countless orphans ran around through the afternoon. For a time, I forgot where I was and who I played against, just focused on the ball between our feet. The unifying power of futbol will forever be undefeated.

Our visit to the orphanage was a flash in the pan. I held no illusions that we had made a big difference by showing up just once with a dozen boxes of medicine and patting ourselves on the back for a job well done. This would not be our moment to change things for these boys. It was, however, our chance to take a mental note; we’d be back to Kabul no doubt, and this place would be squarely in our plans.

‘I wonder if that’s maybe the biggest place we could really help,’ I said to the group that evening under the stars. ‘Yes, we aren’t here to overhaul systems, nor are we here to build governance or stimulate the economy. But you know what we can do? We can take that orphanage, and flip the whole thing upside down. Give 400 children a real future that they’ll otherwise never have. Produce 400 contributing members of society with a mission statement to go out in the world and become agents for positive change.’

‘Now there’s an idea,’ Tayseer said.