Sylvia's Journal

That Obama was in town we found out from our internet news sources when we got back home after a long day. We could have suspected that something was afoot when the acting minister excused herself, at the dinner she hosted for us, right after the soup. She met indeed the man who she admires so much.

We also could have known something was going on from the continuous droning overhead. It sounded like the low rumble of distant thunder. These were the helicopters and airships to protect our president. Rumor had it that even Karzai did not find out until 10 minutes before he arrived that his US counterpart was about to knock on his door.

Entirely oblivious to all of this we all got up early again and left for the Intercon with a car load full of people, so I got to ride in the back. We are squeezing meetings in before, during and after the health retreat, every unprogrammed hour is used. We started with a strategy meeting about the leadership and management development program. Our in-house leadership specialist (who I count among my own success indicators) presented, using our own challenge model, our mission, long and short term results, some data on what is currently happening, challenges, obstacles and how we propose to move forward.

Some good ideas came out of the meeting: focusing more on academic and training institutions to get the management and leadership development added to the pre-service curriculum so that health professionals start their career knowing how to manage and lead rather than fumbling their way through.

Another idea is the creation of a public health leadership institute as a private entity that can serve the needs of Afghanistan long after our and similar US government-funded projects are gone. It is an exciting prospect that we ought to start working on now. It would be a real legacy.

In the meantime I continue to use every chance I can to model how you can deal in a polite way with people, especially the most senior ministry staff or distinguished external guests, when they are using the plenary session in improper ways. There is a degree of passivity, or maybe it is fear, that allows moves from participants that derail the carefully crafted group-genius processes that we are trying to pilot.

I have a few allies and it is wonderful to see them thinking along with me. They recognize the power of structure for ensuring true participation rather than the pseudo participation that usually goes by the name of ‘questions and answers.’

Some of the sessions went better than imagined, some a little less but at the end of the day people were pleased to have been heard and I was pleased that everyone knew a little more than they did at the beginning of the day, at least those who had listened to others rather than themselves.

There were a few glitches here and there and awkward surprises that threatened our carefully designed program, like a last minute presentation added by someone who no one could say no to. I hate these because I appear the only one willing to go to battle to preserve our design. But then, when I do, there often turns out to be a solution that is elegant and acceptable to all. I think I got such a solution during the dinner we hosted for the senior ministry staff. Whether I really did we will find out tomorrow. I do like living on the edge.

I had thought it was a good idea to bring the conference supplies with me to the Intercontinental Hotel as I was to go there anyways to check on the room set up for the Third National Strategic health Retreat that starts tomorrow after 6 months of preparation, nearly the entire duration of m y stay in Afghanistan.

My colleague in charge of logistics would have had to come all the way across town in heavy traffic (on his day off) and then turn around to go back to the hotel halfway back to his home. We are talking hours in the car.

And so I offered to bring the stuff. Little did I know what I had offered. When the driver arrived I asked where everything was, looking into the empty back not seeing any of the supplies I had asked him to bring. I speak in Dari now with the drivers and dispatcher which means that some messages don’t quite get through. It is the price of practice.

I went back with the driver to the office to pick up the bags and boxes that I thought would be waiting for me. Of course they weren’t but it is weekend here so none of the skeleton weekend staff knew where to find everything. After a few phone calls we located the materials and the car was loaded.

When I arrived at the exit gate of our compound I wasn’t able to produce a gate pass and without a gate pass nothing except personal belongings can leave the compound. It is a control measure that makes sense here but not one I am used to. It makes you realize how many of the controls in the US have been internalized and how much trust there is back in our HQ offices that people won’t take what doesn’t belong to them when they leave the office.

Because of all these controls, and the severe consequences for abusing trust, we are never worried about things being stolen when we are amongst our own staff. But the price for this is filling in papers and getting signatures, the right signatures. I naively signed for my own gate pass but the guards wouldn’t let me through. The rule is: you cannot sign your own requests. This is of course a good thing from a managerial perspective. Clearly, our guards are well trained not to budge in the face of people more powerful than them. I think it was fear, for the consequences, that allows them to say no to me.

I tried not to let my impatience come through and with a sigh went in search of a signature – this is tricky as there are only three people above me who could sign and at least two of those were not around. But finally, with the right signature on the right piece of paper I left the compound to find myself in a giant traffic jam on our way to the Intercon. A friendly policeman was willing to change the traffic rules for a moment and let us through across what looked like an impermeable road.

We arrived one hour after the planned arrival and were met with more obstacles; the frequent attacks on the Serena Hotel have made the Intercontinental Hotel the venue of choice for high level meetings. As a result, security has been stepped up. If you think you can just drive up to the hotel with a jumble of boxes and plastic bags in the back you are wrong. Not only did our cargo require a thorough searching at the entrance gate, we were also not allowed to drive up to the entrance of the hotel itself.

I had made friends over the phone with the banquet manager and thought a simple call would clear such misunderstandings. But security is security, and once again no exceptions were made. We had to unload our wares and re-load them in a shuttle bus that took us up the hill to the hotel. There, everything had to be screened again before we could take ourselves and our stuff to the fifth floor. I don’t think I will ever promise to bring stuff again.

The whole affair took so long that I was not able to see my physical therapist before our meeting at the ministry to introduce our headquarter folks to the new (acting) minister. Nor was I able to get my PT session after that as the rest of the day was tightly programmed: lunch, presentations, Dari lessons and guests for dinner. I am taking a little rest while Axel is putting the final touches on our dinner tonight: an Afghan variation on fajitas or a Mexican variation on Afghan food.

If ever I needed a weekend, or at least half a weekend it was today. The weariness of the week ‘s long hours was in every cell of my body and I was aching for a massage, one of the many pleasant Friday activities. When I found out work sessions were scheduled for today I was not happy. Luckily, after some back and forth the sessions were turned into a dinner and I scheduled my massage for 4PM.

We took our usual walk in Bagh-e-Bala which, now that the new year has arrived, is suddenly populated with women, lots of them. Where were they all winter? The place was busy and small tea stations had popped up like weed after a rain shower. We stopped at a place that can now count us as regulars.

On the way home we stopped at an Afghan version of a garden center with prices that were American, probably raised the moment we walked in. Our guard and driver shook their heads, too expensive, and so we left empty handed. Axel was ready for the geraniums but I think we will wait awhile.

We tried to express our interest in buying seeds but could not find the word in Dari. It turned out to be the same word that is used for egg. That makes sense.

We were dropped off at Paul’s house for a lunch with various colleagues from USAID, WHO, UNICEF and the EU as well as one Belgian, the number one man in Afghanistan. It was a lunch rather than a dinner because many of the guests are not allowed by their security chiefs to cross the town after dark. It was a nice lunch, arose de vin blanc et biere, and thus a faint memory of Lebanon; we pretended that all we had to do was get on the balcony to see the Mediterranean.

I did not get the full 60 minutes massage that I had signed up for but the 50 I got were the best ever. I left with a credit for the remaining ten minutes, may be next week. They know me there now.

All limbered up I went home to tackle the continuing annoying task for catching up on 100s of emails that have slipped in while I was sans computer, and working on a new machine that remembers nothing of me and is missing most of my non standard programs; including my Byki program for learning Dari with the remembered and stale items. Having to start from scratch to build up my remembered vocabulary is annoying to say the least.

Just as I was about to settle in for the remaining hours of the day an invitation to join the Boston team for dinner came in and I was torn: it wasn’t work, but still. Axel, already in his pajamas declined but I am glad I joined the others. It’s always a good strategy to be there when your bosses meet. Email dumping will have to wait, and so does the other work that needs to be completed before bedtime. Although tomorrow there is another day, the weekend is essentially over.

I have now observed the minister in her symbolic role, her managerial role and her political role. I finished my second day as a shadow a little bit wiser about the context in which she operates and the enormous variety of roles she has to play. I hardly exchanged a word with her as there was simple no time; every single minute of her time between 9 and 12 was taken by then this then that constituency.

I simply sat in a corner, being a fly on the wall, using one eye and one ear to take in what was happening in the room while with the other eye and one hand I drafted her speech to open the strategic health retreat on Sunday.

After my time was up I attended the closing session of the results conference, showing up just in time for lunch – a bad habit I share with many people. I don’t usually make a habit of this but it just turned out that way.

Steve and I exchanged notes on the experience of being a fly on the wall. Together we are learning some interesting things, but mostly we are learning that the person we are shadowing is doing many of the things we teach about leadership and doing them right.

I returned back to the MSH compound about 3 PM, just when things were beginning to wind down there and people started to prepare for the weekend.

I had hoped to pick up my recovering computer from the IT hospital but learned that the patient was actually fatally ill. It took nearly five hours to get me set up with a new computer which was delivered to my house by our very dedicated IT chief. The internet settings weren’t right so I am still relying on Axel’s Mac to get my story posted, as I have now done for 10 days. I am beginning to understand how the Mac works.

Our new visitor from Boston has arrived. We surprised Joseph with a gin tonic on the terrace; our first day sitting outside at the cocktail hour and actually having a cocktail.

Joseph and I had not seen each other in 6 months, when, before my departure to Afghanistan we saw each other daily. There was much catching up to do.

For dinner we had Will and Lucy over from the Turquoise Mountain Foundation. We served them a Lebanese meal, followed by Lebanese (Arabic) coffee and discovered that, some years ago, they were parasailing instructors taking people down from the top of the teleferique, just below Our Lady of Lebanon, to the sandy beaches of Jounieh, right below the place where we had our exquisite dinner with Mayssa’s dad.,Small world.

We had a lovely meal, during which we talked about vision, mission, challenges and the new US healthcare bill which our Bristish guests wanted us to explain to them. We let Joseph do that, being better informed than we were.

Our meal was accompanied by a great wine that Joseph brought in from Dubai. Things like that are a great treat. We drank the wine out of tiny glasses to make the bottle last for a long time, which it did. Life can be pretty good over here, especially at the end of a long week of 12 hour workdays.

After checking in on my sick computer at the computer hospital (diagnosis complete, ill but not fatally) I joined some of my colleagues on the long ride across a congested Kabul to the ministry to report for duty.

Soon after I arrived HE and I left again to attend the celebration of World TB Day at the Medical School. We drove in a car with special plates that let us go through the US estates and roads that have been taken out of circulation. This provided a considerable short cut although it was essentially back to where I had come from. As a result I spent two full hours in a car.

Shadowing a VIP is a little awkward when there is a red carpet and a receiving line; by virtue of arriving together I got a similar VIP treatment and a first row seat. We had to wait for an hour for the acting president of the republic (the actual one being out of the country), a general whose name has at least 20 page numbers in the index of Ahmed Rashid’s latest book.

I must admit it felt a little uncomfortable at times to be sitting only meters away from someone who in his past and current symbolic role surely must have many enemies. Of course he is surrounded by tons of people with big guns and suits who talk into their collars. This only partially comforted me.

The World TB Day celebrations in Afghanistan are celebrated under the motto ‘peace is a guarantee for health.’ which many American would deny although may be not anymore now that the Bill has passed.

As usual, the event was opened with a recitation from the Holy Quran by an iman, brightly dressed in his beautiful robes. This stood in sharp contrast to the young cantors who appear at most other formal openings, of lesser import, and who always look like they were lifted from their beds or picked off the streets in their shabby and crinkled dude clothes.

Halfway through the speeches the most adorable little boys and girls, who had walked in earlier holding hands, were called to the stage where they performed two cheerful songs exhorting us to work hand in hand and now towards the eradication of TB. They did this with many hand and arm movements and finger wagging to emphasize the importance of their message. One little boy relied heavily on the cues from the two girls on his side and I was sorry I did not have my flip camera with me to record this.

After the songs and amidst loud applause from the audience they received large gift bags, for some half their size, from the vice president and a pat on the head. I was able to show this to Axel on the 8 o’clock news.

Back in their seats at the back of the hall the gift bags were emptied with noisy sounds of delight while Her Excellency the acting Minister of Health was giving her carefully crafted speech – worked on during our ride in the morning.

After the VP had left I decided it was time to find a women’s bathroom in the Kabul Medical University. This turned out to be a big challenge despite the large number of female students I observed. The enormous distance I had to travel and the difficulty of finding this one bathroom made me wonder whether female Afghan students actually need a bathroom.

This is one thing Axel and I can’t get used to: the ease with which people here accept things that would create great indignation at home and produce angry letters to the dean or in the student newspaper. Coalition building here is a political action, not something you’d do to get more female bathrooms.

We drove back with our follower security car turning on its siren whenever a random car threatened to separate us. Once again I wasn’t all that comfortable to be so close to power in a place where power can bring you down swiftly.

By the time we arrived back at the ministry my shadow period was over. I joined my counterparts and colleagues at the Results Conference, day 2 in the middle of a presentation by a Canadian orthopedic surgeon about the processes in hospitals that keep doctors from learning. I was ecstatic about my timing: not only had I found a doctor interested in organizational learning processes, I also found someone to translate my MRI reading into ordinary English.

By the time I reported back to work in our own compound in Karte Seh there was another full workday waiting for me with meetings and presentations and email that has accumulated to over 400 during my computer’s convalescence (it’s still kept overnight for observation).

During the rest of the day I experienced both the joys of working here and the frustrations: joys of seeing my very competent and caring staff at work and frustrations because another conference (number 3 in a row) is called on short notice which requires us to undo all the preparations for an event in Mazar-i-Sharif planned for that same period.

But the worst bad news was that my two colleagues who were going to present at the Geneva Health Systems Forum were denied their visa to Switzerland because there was insufficient proof that they would return to Kabul. They traveled to Islamabad in February and dropped off their passports. They returned yesterday to Islamabad to retrieve them, hoping for the stamp they didn’t get. I don’t think I am going to be as accepting about this as they seem to be.

It was a sobering reminder of how difficult things are for Afghans: finding a women’s bathroom in the medical university and traveling to present at a conference in Geneva. People may think life is difficult for us here but it is nothing compared to what Afghans have to suffer every day.

Today I spent the entire day at the ministry. We all traipsed out from our quiet Karte Seh across town in one of our minibuses. They are referred to as the Flying Coaches, which, when pronounced fast by a Dari speaker sounds kind of Dari (flakatsch). This to distinguish them from the more comfortable Toyota Landcruisers. I do prefer the flying coaches because they take more people. This invariably means more stories, more jokes and much more practice of my Dari.

The Results Conference has been in the making for many months. Although the preparations were a bit wobbly, the first day of this long awaited event was beyond our wildest dreams: excellent presentations, excellent people, excellent food and a sense of camaraderie around the common goal of improving health care for Afghans that made us all proud and feeling warm and fuzzy inside.

Most of the presentations were of international conference quality – a far cry from what was the norm only 8 years ago: clumsy, bad English, low confidence, poor logic and data. Now we saw confident people presenting interesting and sometimes very compelling data and ideas, asking and answering questions with great confidence and ease. The capacity building that has happened here and in Australia, Japan, India, Pakistan, US and UK has paid off. In fact there are other countries that want to learn from Afghanistan. If you can accomplish some spectacular health improvements here, there is no excuse not to, elsewhere!

One of the more memorable presentations was by an engineer from the Ministry of Mines who spoke to us about the findings from a survey of the air quality in Kabul. We knew it was bad but not how bad. The stuff that is burned here: plastic, wood, motor oil, rubber tires, diesel fuel is pumping high concentrations of NOXs and VOCs (essentially toxic and proven carcinogenic gasses) into the air and thus our lungs without any discrimination.

These gasses, the high altitude, the presence of nearly year round sun and the fact that Kabul lies in a bowl produces high concentrations of ozone which is the stuff, he explained, that makes the mountains around Kabul disappear on a beautiful summer day at the end of the morning. It decomposes rubber bands and tires in no time so it can’t be good for our lungs. There were some choking sounds in the room as he went from one scary slide to another. This is what the danger pay is really for: a lung fund to rent a retirement flat in a sanatorium in the Alps.

He quoted liberally from US and Canadian environmental health policies and ended his show with a list of short term and long term strategies that have worked in the US in places with similar geographic qualities, like Denver. One of his bullets was ‘stop smoking vehicles.’ I imagined the illustration Sita would have made hearing this recommendation; it made me chuckle. Unfortunately any progress on his recommendations is unlikely in the short run due to the inability to enforce anything and the opportunities that are offered to (and allegedly often embraced by) those tasked with enforcement to making some quick and big money on the side.

In between presentations we had meetings with the deputy ministers about strengthening leadership at the top. After some quick and effective interventions from our main donor, I found myself with a new assignment: to shadow the acting minister for a while until we can figure out how I, with all of MSH behind me, can best support her. It is a dream come true after all my years of preparing for this moment. I am supposed to report to Her Excellency’s office tomorrow at 8:30. At noontime I will return to the MSH office and Steve takes my place for the afternoon to help with things of a public health and technical nature I know little about. I will be focusing on the management, leadership and organizational processes at the top levels of the ministry. Imagine that!

I have started to use our new exercise equipment and run elliptically for a little while each evening before bedtime. The combination of being out of shape and at an altitude of about 6000 feet produces a sorry record: 1 kilometer in 5 minutes leaving me gasping for air on the bed. The first part of my self-imposed training is discouraging but I want to give it a try.

At the same time I am struggling with the deteriorating shoulder and not sure what to do about it. I hope the military physical therapist is still embedded at the 400-bed hospital so I can show him the MRI result and see what he recommends as my current shoulder exercise regime is also a bit discouraging.

My first day back at work was long and entirely managed without a computer. Still I felt as if I was missing a limb, so much has the computer become part of my life, and more specifically an extension of my brain and my senses for both input and output.

Things are simmering at the ministry and new roles are being explored for Steve and me. There’s even talk about an embedding sort of arrangement, with each one of us assigned to the sit with the highest levels and serve as a sounding board in the midst of this tangle of political, technical and organizational forces that would overwhelm just anyone.

All of us expats came together for a farewell dinner at guesthouse zero for Kip who is leaving for good. He explained earlier today to our Afghan colleagues that not being able to engage on foot with Afghan society and never learning the language were his two big regrets and the former the reason for his premature departure. Being cooped up like we are isn’t fun, indeed, but we are trying to compensate for that by learning the language and expanding our circle of Afghan friends. Still, we all know what he meant and nodded our heads.

Axel instructed our cook this morning to make a recipe out of the Lebanese cookbook, a lentil soup that looks and smells like I imagined it should; only the serving suggestion was missing (a few dollops of yogurt). This was rather encouraging.