My husband works in collaboration with the US Agency for International Development, and I decided to move to Kabul, Afghanistan, to be with him, as well as to work medically. My hope was that I could express love and concern to a group of people that I knew had suffered tremendously. I learned of an American family practice physician who was working at a local clinic, and I went to meet him. He welcomed me on board. From the summer of 2007 to the summer of 2009, I worked in the clinic as the Mother-Child Health Coordinator. My
goal was to improve the clinic's services for women and children.
■ 7:00 AM
I walk out my front door and wave to my driver that I'm ready to go. After a violent incident near our home, my husband and I decided to improve my security by hiring a private driver. I pile several bags into our Corolla; I always need my personal medical equipment; references; and teaching supplies, including cake for the students. Off we go, weaving through the congestion of pedestrians, bicycles, cars, buses, goats, sheep, and armored personnel carriers.
I'm in a bit of a rush today because I need to teach a class for the midwives before the receptionist checks in patients. Because the clinic does not have an appointment system—that would require literacy and telephones—patients create a long line on the street in the hopes of
getting inside the gate before the guard yells, "Stop." Every day, I have to push through this crowd to get to work. Once inside, I gather the midwives for their class. The midwives are some of the most highly trained women in the country; all of them have 2 years of university training. They are excellent at delivering babies but have never been trained in prenatal care. Our goal is to create the best prenatal clinic in the country and make prenatal care available to very poor patients. Afghanistan's maternal mortality rate is the second highest in the world, with about 1,800 maternal deaths per 100,000 live births,* so the need for good prenatal care that prevents poor outcomes is enormous! We sit down and get to work. Today's lesson is on nonstress testing.
■ 8:30 AM
The waiting room is getting very crowded. I go into the reception room, grab the stack of charts, and turn to leave; then I catch myself and stop. Everyone is smiling at me; they know I just skipped the profuse greeting I should have given before grabbing those charts. We stop, we greet. We kiss or hold our hand on our chest. Then we greet again. Now everyone is laughing, and I'm free to go.
I start calling out names ... Shukria ... Zia Gul ... Spin Bibi. As the women enter the OB/GYN wing of the clinic, which is for women only, they lift up their blue burkas so their faces are visible and find a place in the Vital Signs room. Here, their vitals and complete prenatal history are obtained.
■ 8:50 AM
Vitals and histories are complete for several patients, so I leave one midwife to continue while I start seeing the patients one by one. I call the first patient into the exam room. She is a gynecology patient hoping to get help with her infertility problem. I have seen her several times in the past and referred her to a specialty clinic for the necessary labs for further diagnosis. She refuses to go, however, so we keep trying. She was severely beaten by the Taliban many years earlier and sustained neurologic damage that resulted in a severe speech impediment and lack of ability to show facial expression.
The next patient is one of many for the new prenatal clinic! She is 34 weeks' pregnant and has already had lab work and an ultrasound at earlier visits; today we check her vitals, fundal height, fetal heart tones, etc. No problems are detected, and she is asked to come back again in 2 weeks. The morning goes by quickly, and about 20 patients are finished by noon. We work as fast as we can because of the long line of patients outside. If a midwife is available, I work with her as a team; one of us writes in the chart and the other performs the exam. Although several Afghan doctors work at this clinic, I am the only female clinician. The culture of Afghanistan is one of tremendous modesty; female patients do not go to male clinicians for problems of a very personal nature. As a result, all the OB/GYN patients were sent to me.
■ 11:47 AM
The clinic's maid knocks on the door. A woman in labor has arrived. Instantly, she is given priority. Her membranes have ruptured and she is dilated to 6 cm; her contractions are strong and 5 minutes apart, and the baby is in vertex position. Vitals are normal. We admit her to the delivery room. If any abnormality had been present, she would have been transported to a nearby hospital. The midwife goes with the patient to the delivery room and starts a nonstress test. I return to my other patients and, like every other day, work straight through lunch. I cannot stop to eat when I know there are still many patients who have already been waiting several hours.