So, how do you build an enduring military healthcare system in one of the poorest countries in the world? How do you do that in the face of an active insurgency? How do you do that in less than ten years when it has taken the US a couple hundred years to do it? Where do you even start? What are the priorities?
Our #1 challenge is recruiting, training, and retaining an adequate number of qualified medical personnel. We still need to train 3700 more front-line medics, plus 130 more nurses and 380 more physicians to support an Afghan National Security Force (ANSF) of about 190,000. As the ANSF grows, we will need to double or even triple the number of trained medical personnel. Our current projections are that we will have sufficient numbers of medics by 2014, nurses by 2016, and physicians by 2020 respectively…more than ten years from now. This year, we started a military medical and a nursing school, regionalized Combat Medic training, and expanded the Allied Health Professions Institute for laboratory, radiology, and ultrasound technicians to include preventive medicine technicians. I have to say that one of my proudest moments this year has been attending the graduation of our first nursing school class. There we recognized the five graduates who had scored higher than 95% of the Afghan civilian medical school graduates who had rotated through the intern program at Bagram Craig Joint Theater Hospital. There is great hope for a bright Afghan future.
Compared to the daunting task of producing sufficient numbers of well-trained medical personnel, buying them “stuff” is the easy part. This year, we have been building 50-bed expansions to the five 50-bed ANA regional hospitals. Those are in addition to the 50-bed ANP Hospital and 400-bed National Military Hospital, considered by many to be the premier medical facility in Afghanistan, both in Kabul. With over $50 million available to us for construction and equipment, we are well supported. The challenge is that we must always balance what we can acquire for the Afghans with what we should acquire for them. For example, there are nearly constant requests from some of the regional hospitals for CT scanners, a very reasonable request considering the volume of trauma some of them treat. However, does it make sense to install such equipment when they do not have “clean”, reliable power? Do they have a radiologist trained to read CT scans? How about a CT technician to run the machine? The answer to all of these questions happens to be “no” for now, so now is not the time to acquire these machines….maybe later when all those other prerequisites are in place.
If buying them “stuff” is the easy part, getting the Afghans to change their behavior is the tough part. The former Soviet command and control (C2) systems and attitudes are still very much ingrained in many of the ANSF leadership. Three of my biggest mentoring challenges are getting leaders to take initiative, delegate responsibility, and hold themselves accountable. It is common for a principal (an individual whom we are mentoring) to verbalize understanding and agreement that a certain task needs to be accomplished, yet refuse to act until a superior gives them a written order to do so. It was a happy day when the ANA SG proudly showed me the daily report his staff had initiated to summarize management level information from their five hospitals and eleven 20-bed clinics. Yet delegation is not something that comes easily to a culture where control of “stuff” is tantamount to power and a hedge against logistical famine. We are slowly making progress in teaching that the reason for having that “stuff” is to ensure that it actually gets used to the appropriate benefit of patients and the unit mission. And if someone makes a mistake, even if it is an elder or a fellow tribesman whom you respect, the correct response is to hold them accountable and teach them how to improve the situation for next time. We are not here to build a US standard of healthcare. We are here to build the best possible Afghan standard of healthcare. It may take ten to twenty years to get there, but we are helping them get there.
