After being woken by the sounds of Morning Prayer the following day, I got the ultrasound probes and tablets together before heading down to meet the team. Once everyone was assembled in the lobby, we got in the cars and got on the road. Rush hour traffic in Kabul was an experience, and after traversing through streets lined by soviet era infrastructure and clothing vendors, we pulled into Maiwand Teaching Hospital.

The medical branches of our project would be split between two hospitals: Maiwand Hospital would be the site of our pediatrics work through Dr Adel and Amanda, whereas the adult medicine teams would be at Aliabad Hospital. Both of these were of the Kabul University Hospital network.

On arrival at the hospital, we were met by a local physician who led us into the office of the medical director where we sat for a while and were given tea and sponge cake. Once the director of the hospital arrived we introduced ourselves collectively and they brought us to a conference hall where there was a formal introduction with the local staff. In the process, several members of the hospital administration said some words. One in particular stood out to me, it was a pediatrics physician on staff.

‘We thank the Pious Projects team for their generosity and desire to help us improve conditions for Afghanistan,’ he said. ‘We are a nation that has been through much hardship, and our services are desperately lacking in equipment and skills with a neonatal mortality rate of 35%. We look forward to working together.’

Neonatal mortality of 35%? I thought to myself. That’s nearly incomprehensible.

After the conference, we left our pediatric division at Maiwand and the rest continued on towards Aliabad Hospital. Arriving at the gates, we kept our security personnel with us despite the “No Firearms” sign on the front and drove up a driveway to the main entrance of the hospital. We were met this time by a few different staff members, the Director of Higher Education and the head of the internal medicine department, who ushered us towards the office of the Hospital Director. Again, we were met with tea and sponge cake in quantities too great to consume (this would become a common trend, hospitality and warmth playing a huge part in the Afghan cultural identity). As we waited for the arrival of the Hospital Director, Abdullah and I learned more about the medical structures from the head of medicine.

The medical training structures in Afghanistan had some parallels and differences to the systems I knew from Africa. Medical schools train general physicians who then do a year of internship before becoming independent medical officers. Through a few medical schools, medical officers then have access to residency programs in medicine, surgery, anesthesia, pediatrics, radiology and dermatology, but a notable lack in subspecialists and subspecialist training pathways. Many physicians leave the country for subspecialist training in Pakistan, India, or Iran. At Aliabad Hospital, all of the staff in the internal medicine department rotated through all of the different services, meaning that medicine staff didn’t get the chance to pursue higher caseloads in their own areas of interest. The residents in the building made up the majority of the workforce, typically covering 2-3 patients each and reporting directly to a consultant in medicine, who would round on all patients every day. As such, medical ‘teams’ in the way that I knew them didn’t really exist here. Most doctors also split time between the university hospitals and the private sector due to the lack of funds to provide public sector physicians with competitive salaries. This meant that residents often-times did as much as they could before leaving for their public sector jobs around 1:00PM, and that consultants had to balance their medical school lecturing, clinical work, and bedside teaching in an equally compressed schedule in order to make it to their more lucrative posts in the private sector. This push-pull from the private sector was not unique to Afghanistan at all, as the same happens in most countries with two-tiered health systems. All of this is to indicate that already in my short career, I was identifying recurrent trends in low-income health systems.

After some time chatting, the Head of Medicine took us on a tour through the wards. They were relatively clean and had ample space, but were underequipped. The hospital building was 90 years old, and it wasn’t clear whether any notable renovations had happened at all since its construction. Entering the male and female wards, sinks were hard to come by, and even when I did, many didn’t work. In the medical ICU, there were no oxygen wall lines, so patients on oxygen were reliant on large refillable tanks that regularly ran out without the nurses realizing. There were no medicine pumps in the ICU either, meaning that knowing what rate infusions were running at was impossible to know. When doing procedures, drains ran from body cavities into plastic soda bottles. Gloves were a commodity as well, as was hand sanitizer. When it came to diagnostics, the absence of a microbiology lab meant that all infections were treated empirically (meaning using the best antibiotic for the bacteria causing an infection came down to an educated guess based on the patient’s features instead of isolating the bug in the lab). These were a handful of the things I noticed in only thirty minutes of walking through the building.

Still, tours don’t tell the whole story. The real reason I was here was not to drink tea, eat sponge cake, or evaluate medical equipment, but to bring a tangible skill that could benefit patients through clinical teaching and capacity building. The first day of a mission is always filled with lost time in introductions, I have come to expect this. Westerners exist in a bubble of obsession with efficiency, and quite frankly the rest of the world doesn’t operate that way. So, despite some lament that much of our day was spent in ornamental displays of action, once the afternoon came around, I set up in the 6^th floor conference room to give the first session in the five day crash course in point of care ultrasound.

The schedule for the course had already been set when I met with the Aliabad department heads by Zoom to discuss implementation of our training. So, the first sessions of the day were the introduction and scans of the abdomen—easy stuff. We had a full house, with around 25 residents from various departments, and the Heads of Medicine, Radiology, and Higher Education. Since all of the higher education was in English, I didn’t have to make much use of the translator, and before long I was yapping away in my usual fashion.

The classroom teaching was followed by a scanning session in a nearby room, and I got everyone to hold the probe and familiarize themselves with the tech and the scan. This took us to the end of their clinical work day around 4:00, and we packed up before meeting the rest of the group out front and riding back to the hotel. All in all, I had a pretty good start to our project, with enthusiasm and uptake from the local staff.

The rest of our team could not necessarily say the same. That night we all met in the hotel conference room for our first nightly debrief session. Many of the typical frustrations of humanitarian work surfaced during our discussion. Adel and Amanda at Maiwand found infrastructure lacking and training not to an international standard. Furthermore, a lack of redundant staffing meant that in order to deliver training for neonatal resuscitation, we would have had to pull nurses from their clinical duties, and others would still have to leave in the afternoon for their private sector jobs. Abdullah in the ICU found an unfortunate sense of apathy from several of the physicians—not unexpected, as this is a common manifestation in convergence of burnout, poor pay, encumbering systems, resource limitation, and lack of hope in resource limited settings—as well as little appreciation for infection reduction strategies across the board. To say that I was surprised by any of this would be a lie, after all this is exactly why we were here; finding a healthcare system without these flaws would actually signal a bigger problem.

The same way that a doctor wants sick patients, humanitarians want populations in need; otherwise what the hell are we doing? The question then becomes establishing a diagnosis and deciding on a management plan, which is where things get tricky. Unlike in medicine, there are no clear diagnostic tools or guidelines to do the thinking for us when we evaluate the needs of a health system. So inevitably, our debrief session spiraled from a conversation about our day to a philosophical discussion about our line of work in general. The impetus for change couldn’t just come from us, twelve foreigners in a conference room, it had to come from within which meant someone had to buy into our interventions and champion them in the intermediate to long-term. We were talking about fundamental shifts in the attitudes around the practice of medicine that are tied to everything from social memory to economics to governance and culture. These shifts could not happen overnight. So, despite the grandiose desire to rebuild Afghanistan, if you were to ask me, I would tell you that we had to decidedly stay true to our mission and nothing more: deliver services, empower others through training, inspire hope through our presence, and above all, build partnerships