Innovation in Humanitarian Work During Geopolitical Crisis with Dr. Mohammad Haqmal

Living a life in full is a conversation you always wanted to have with that person who gave an amazing TED Talk, or the author of one of your favorite books, or that inspirational Olympian you always wanted to know more about. It's graduate level conversations with those making a difference in the world and in the lives of others. This show brings you new ideas and approaches so that you can live a life in full. I'm your host, Dr. Chris Stout and I hope you enjoy this episode. This episode is sponsored by our new video course, how to Publish in the New Millennium. From Scientific Journals to Best Sellers, it's an asynchronous course offering so you can watch it when it's convenient for your schedule. It's based on eight video lessons and provides three hours of material with new concepts, stories and examples, and it includes several attempts at humor. You'll learn about the best ways to submit a manuscript to a peer reviewed journal, the mechanics of book contracting, what publishers are looking for, how to evaluate and negotiate a contract, royalties, advances, copyright and ownership, why to never first submit a manuscript to a publisher when you need an agent and when you don't, and the differences between publishers. You'll learn about ebooks, print on demand, Amazon's CreateSpace and KDP programs and other non traditional approaches to publishing, along with how to tell if a platform is of high quality or not. We do a deep dive into marketing, how to create media kits and what goes into them, along with examples how to create a great Amazon author page, how book signings work and how to be invited to do library talks and the economics of both, along with developing speaking engagements, promotional tours and being a podcast guest, as well as a number of other publicity aspects. We cover blogging and provide additional resources to help you in crafting your work and making it better. This is a rich, fun and fact filled course that covers everything you need to know from a practical and actionable perspective. It's for anyone wanting to get their written work into the world, be it academia, popular media, or both. Join the Masterclass in Getting Published. To learn more, please visit tinyurl.com Getting Publishers Published Course thanks welcome to another episode of Living a Life in Full. I'm your host, Dr. Chris Stout. Dr. Mohammad Hakmal is the former Chief of Public Health for Afghanistan where he developed a series of groundbreaking programs. He has experience in leading national and international programs and organizations as a regional technical consultant, project Director, country Medical Coordinator, lecturer and researcher for almost two decades. He has expertise in the fields of program management, capacity building, maternal and child health, infectious Diseases research and policy and strategy development. He has led the implementation of large scale development programs for the World bank, usaid, gavi, the Italian Government, the un, the European Commission, and others at the national, provincial, district, facility and community levels. Dr. Hochmal was a Schevening Scholar and in recognition of his groundbreaking initiatives, he has received the Afghanistan National Public Hero Award twice. He's a medical doctor by training and also holds master's degrees in Business Administration, Public health with a focus on epidemiology and global health and development from the universities in south asia and the UK. Dr. Hochmal is fluent in English, Pashtu, Farsi and Arabic. Currently he's a lecturer at the University of London. And as we were talking off mic, I believe he's got a new position lined up at Cambridge. And he's also involved in a number of research projects based in the uk and serves as a columnist at Arab News and has a forthcoming new book. Welcome to the show, Hakmal. It's great to have you on.

Thank you very much. Pleasure. Pleasure is mine.

You know, I have just a very minimal connection with Afghanistan, so I have kind of like a lot of questions. I'm sure a lot of our audience members do, but a number of years ago I worked with a place called Eureka Research and was invited to work on the development of a think tank with an entity called Q Holdings. Back in the day. I don't even know if those things are still around. And I guess my current awareness with the recent events of the US's withdrawal is kind of, you know, here in North America kind of brought that to the fore. But perhaps as a place to start, you could tell us about growing up there, your childhood. I know that it was pretty challenging, so might that be a good place to start?

Well, thank you very much once again for having me in your program. Yes, as you mentioned, you know, like I'm born in Afghanistan originally from, I'm from Afghanistan, but then we left Pakistan and 1980 as a small child and I completed also my school, you know, high school in Pakistan. And then I returned back to Afghanistan in 1996 and I started my medical school in Kabul. I was a medical Student association head during the previous Taliban government from 1996 up to 2000, 2000, and then I graduated in 2003 from Kabul University. So I had, I had, you know, I was refugees in Pakistan, then in inside Afghanistan because of these challenges. We were also among these internally displaced people. Originally I'm from local, but I was living in Kabul. So most of the time I was from family just to pursue the educations and I was just traveling, following my school, wherever I was supposed to go. And I was happy to take that risk.

I can imagine, and I've read doing some background that at the refugee camps you were pretty resourceful as a child or as a young man to kind of do some entrepreneurial kinds of things to be able to get funding and things. Can you tell us a little bit about what your ingenuity was in that area?

That's absolutely true because it was not only me, there was also, let's say, thousand other refugees, specifically in those children, you know, that they had no resources, either from family or also from the governments, also from the international community. So I was also among those children. I was selling water when I was 6 years old and I was also feeding, you know, helping my family. And specifically on weekend, which was regularly Friday and Pakistan for refugees, you know, so every Friday I was working and apart from Friday, I was also selling, you know, like sometimes vegetables, sometimes fruit, you know, most of the time water, which did not really need like, you know, more investment, you know. So it's easy, you know, to buy some ice and put it in a basket and then sell it water, you know. So that was my part time job and I was enjoying that one, I think, you know, for very long time until I completed my school.

Wow, good for you. Well, what was it that drew you into medicine and can you tell us what that journey was like?

Well, because when I completed my high school in Pakistan, so then I also passed exam, you know, for the entrance exam, you know, to medical school in Pakistan, among those for these refugees universities, specifically for the Afghan. So I was very fortunate, very fortunate. You know, I got the highest score among, in the exam for both universities. So one was, you know, from one, one from one political party. The second was from other political party, you know, me, somebody who was not well connected, you know, those political party. So I think it was very merit based, you know, selection. You know, I got, I got the second in one university and fourth in another university. And then unfortunately again in those Afghan Fuji's university, still they were charged, they were charged. They just started, you know, charging, you know, fees and I could not afford that one. Then I came to Afghanistan and again, you know, when I attended that exam, you know, university entrance exam, I also got the highest score and fortunately I was accepted, you know, at another Afghan university which is called Ningarhar Medical faculty, you know, so. So that was one of the best time in my life. You know, wow. To see, you know, having, you know, those all challenges and then get, you know, the chance, you know, to go to the medical school. Because in Afghanistan it was very tough to go because they said there was very limited set. You know, I think it was. We. There was over 3,000 people that we attended the exam. Out of 3,000, they were only selecting, you know, like there was space for 55, 0.

Wow.

So I was very lucky, you know. And so after those challenges and limited resources in my life, selling water table or fruit, living in a tent for very long time, very long time. And apart from that, I remember I could not afford for very long time to buy shoes. And I was wearing all the times, plastic sandal.

Oh, my gosh. So.

So with those sandals. I enjoy that life with sandal as well, you know. So I think that was the best time, you know, when I passed the exam and I got the chance, you know, to start my medical school in Afghanistan. And so later I was shifted, you know, to Kab University because we were thinking, well, Kabul is the capital of the country, so Kabul will be the best one. And then that I also fulfilled the requirement, you know, to move, you know, from regional, you know, medical university to the capital one. Then I. During the Taliban time, we had again, you know, there was a big challenge because during the previous Taliban government, between 1996 up to 2001, so there was no hostel for us normally in the advanced government system, you know, so they are providing, you know, hostels and also education is free at university, public university. But due to limited resources with the previous Taliban government, we work deprived of having, you know, most of to receive, you know, those public services, including, you know, food or maybe, you know, even the electricity, we. We could not manage, you know, to have electricities, you know, we were just using, you know, very classic traditional life living, you know, in a very limited resources, you know, full of challenges again in Kabul University until I completed my. Until the. With the. Let's say, with the support of the international communities that they came to Afghanistan. I think it was 1990, it was 2001. And then we started, you know, at least, you know, good life. And at least during the last two years of my medical studies, you know, I was very lucky enough to have access, you know, to most of those public services supported by the international community.

Gotcha. I know that from our prior conversation that there might be some areas that are sensitive, so I want to be very respectful of that. So there, if there, if I inadvertently ask something that you don't Feel comfortable talking about, you know, just, you know, feel free to say that that's perfectly fine, but I want to maybe shift into more. Like this isn't super recent, but you were, as my research says, the chief of Public health there in Afghanistan, did a lot of really impressive work there. What was it like at the start with becoming the chief of public health? What kinds of things did you work on when you first got started?

Well, let me tell you something very interesting. You know, so when I completed my medical school, so I came to my. To inform my mom, you know, that I completed my medical school. And she was like, she had, you know, big challenges. She was telling me, oh, my son, we don't have, you know, for tomorrow food. So you are graduated. So what will be the next step? Please go and start work as soon as possible and bring some food to our house. And just when I came and I think in the middle of the day, I left back, you know, and was just searching job, you know, in Kabul. And because of this, because we had no elect, no Internet facilities, no computer and I just printed my CV and I was distributing, you know, on all those offices if they are really looking for someone. And when I saw somewhere MSF Medicine Sense frontier, I thought maybe MAS medicine even I was not sure about this. M. So when I did the interview and I was selected, you know, as a hospital director in Central Highland, you know, in a very remote area that nobody was ready to go there, you know. And that road was like, you know, that route between the hospital that I was working for and also the capital of the provinces in Avon. Kabul was most mostly closed for four months during the winter. So I spent the whole winter there and I started working with MSF then. Working with MSF always helped me to dream a little bit bigger and to apply for different position. And then gradually, first nine months I was working as a hospital medical director, you know, in a district level. Then I moved to the provincial level as a clinical supervisor with a different organization. Then I moved as a project manager also with Aga Khan Health Services. It was also a kind of international organization in Bamyan. Then I, within 17 months I got, you know, the highest other position as a country medical coordinator with one of the French organization. And then I came to the Ministry of Public Health for the first time. It was 2008 when I start my job as a district health system manager, you know. So I started something, you know, for the district health system as a from scratch. So I still. I can. I had that privilege, you know, to be Considered district health system founder in Afghanistan. Afghanistan between 2008 up to 2012. Once we completed that pilot project in Afghanistan, it was also World bank funded project, one of the biggest project. And then when the evaluation was done, the guy who was doing, you know, the research of the project, he was a lecturer at the University of London, we call it London School of Hygiene and Tropical Medicine. And his name, he encouraged me to apply for some scholarship and do a master degree and either in US or in uk, you know, so that will also help you a lot, you know, to have a better understanding, you know, and then you can also achieve, you know, the biggest dream that you have in your mind in Afghanistan or outside once you have, you know, the international education from the international recognized university. So then I got the Chevening scholarship funded by the UK Foreign Ministry. And I was also again very lucky. There was I think 2500 people, you know, something like that one. And I got, you know, the second position during the test and intervene application process. And I was lucky, you know, to come among those 15 tuning scholars, you know, to UK and did my master here. And then when I returned back, I think, you know, then I had, you know, more capacities and also better capacities and also more opportunity to think about that one. Because of my connection with the national universities also back in Afghanistan. I was, I also did in a very unique, you know, research project during my master's thesis project. So I was just, I was measuring hospital efficiency to see because it was just 2013 and then 2014 was there where the international community was supposed to leave the country. So it was a big question for the afghan government because 75% of the Afghan government, you know, Health Ministry was funded by the international community. So we were just in a depressed situation. We were, we taught well, if the international community leave the country and then they reduce, you know, their foreign aid, how much that will also affect, you know, the health system. So the best ever, you know, research project that I selected was like responding, you know, to one of the public, the government, the health professional, whoever was like looking, you know, to the health system was thinking, you know, so if the budget is reduced by 20%, how much, you know, the achievement will be reduced? So I found that, well, a 1 with 30 reduction of the health budget. So still, you know, so that was the level of inefficiency. So 30% wastage in the health system budget at the hospital. They will be hard in 34 provinces. So and then I think that was one of the best research project. And then I was Encouraged also by the Minister of Public Health also in Afghanistan to come and also present it to the donors. And then I also had a chance to present it also to the Presidential palace so that presentations in different area. And then fortunately I was also invited to the U.S. i had that presentation in the annual conference at the American Public Health Association's International Health Economic association in Europe. And then I was also invited back at the University of London to present that research project because it was responding, you know, to a question that everybody was just waiting for such kind of, you know, challenging, you know, things. So that challenging thing I was enough lucky, you know, to to do that one. So this further encouraged me and to think deeply. And then in Afghanistan I was also able, you know, when I got the senior position to design several innovation in the health system, including Afghanistan Healthy village initiatives Afghanistan $1 project where we were also focusing on the to reach unreachable people at the community level. So we taught the. When I return back to Afghanistan and I completed the dissertation, the research project about hospital efficiency. We also found that well, there might be also some area in the health system where the projects the national strategy and policy need to be revised because maternal mortality, child mortality was still high while the government or maybe the international community funding enough budget. And then there was unspent budget. And so maternal mortality, child mortality was reduced between 2003-2011 10. But later specifically maternal mortality was just increased again. And I had that level is that I presented, you know, as a unique presentation also at the leadership of the Minister of Public Health donors, most of the embassy representatives, including us, uk, Canada. We told them, well, we need a kind of innovation in the health system to see some local initiatives, local context solution, how people in the area could properly use the services. Even if the services are there, people are not ready to use that one. We need to find out that reason and then tackle it through a local context solution. Because of the international policy strategy were very successful for the first seven, eight years. But later we were not very helpful also in the health system. So then I designed Afghanistan healthy village Afghanistan $1 project. And then we were going beyond that one to see how to improve, you know, this maternal health, child health. Because maternal and child health was, you know, the main challenges in the health system from 2003 to 2011 12. You know, that I was just focusing on that area so that those innovations help us a lot save more life in the remote area. And then I was averted. You know, Health Hero worked even in UK as well. And then In Afghanistan as well, you know, by different political parties, parliament. And that was something, you know, that I was really grateful, you know, for those people that they could. They recognize also our achievement.

Yeah, yeah, I think those are well deserved honors. So in making those kinds of impacts, was it around issues of nutrition or public health or vaccinations or what were the kinds of interventions that you were able to institute that were, you know, creating these wonderful outcomes?

So there was five main area. First was, you know, like delay and receiving services. So mainly, you know, maternal mother, pregnant woman's, and also children when they were also brought in order to receive the services and the health facility. So they were coming at very late stage, you know, so there was three delay. First delay was like taking decision in their family to send that pregnant woman to beat it, to delay to deliver at the health facility level. Second delay was coming, you know, from the house through the help to the help facility, like transportations, you know, so there was difficulty in accessing, you know, the help facility. Third delay was even at the health facility level. So sometime when they were coming at the midnight, so there was no one at the health facility or the clinical level to receive that patient. Or maybe sometime, you know, the health facility staff were like absent. So this was the, the in term of, you know, accessing, you know, to the services. Third one, we also had some, some of the. Because the. It was a kind of national package. And so in some area where we know we have no, you know, even malaria cases based on the national package. So that helped those health facility was still receiving, you know, malaria treatment medicine permanently. Yeah, because this was included in their national package. And then for nutrition, most of the time, like they were waiting, you know, for the patient to come and specifically those malnourished children or even if it is anemic woman, you know, to come to the health facility and also receive the health services there. And what we did with our team, we did an assessment in the health facility and we spent, let's say like maybe one month in those clinics and hospitals that we were trying, you know, to target, you know, the community. Then we spend also around one and a half month with the community. And we were asking them why they are not using the services. So some of them, they were telling us, well, if you go to the clinic, so there is no mask, we will miss our pray. So this was one of their concerns. Second one, they thought, well, when we are coming to the clinic, so some of the doctors in the clinic, they don't understand our language because they are coming, you know, from the capital of the province, where the doctors were like, feeling more privileged, you know, being as a doctors, not carefully listening, you know, to those local terminology. And then for the pregnant women, when I also asked, you know, the same question from the midwife, so midwife was telling me, well, my responsibility is to help pregnant women when they come to the clinics, but I'm not responsible, you know, to provide services at the community level. So and then we also found the role of the informal healthcare providers, you know. So unfortunately, informal healthcare providers, sometimes they were paying the kind of of negative rule and providing, you know, the better services. So, for example, traditional bed attendants that were not registered, you know, in the health system, they were still playing an important role also to conduct some of the deliveries. So when I visited, you know, those rooms where they were conducting the delivery, so that was full of infection, you know. So if the delivery is happening, you know, in a place which is full of infection, then we cannot expect, you know, like to be saved, you know, those pregnant women after delivery.

Oh boy.

And then it was the same. It was the same. So some of them, some of the patient that they were getting disappointed, you know, from the services that they were receiving from the clinics. So then they were going, you know, to the traditional healers and also to the religious scholar for the religious treatment. And I also had, you know, chance together with my team to visit also the religious scholar. And we asked them, you know, which kind of treatment you are providing. So it was very strange and very unfortunate when I heard from the religious scholars and he was saying that, well, I advised them for 40 days specifically for the pregnant women not to eat anything and only drink, you know, water. And so there was a piece of paper, you know, where he was also wrote, wrote some religious treatment, you know, and then put that piece of paper in the water and also swallow it also and drink that water. So for food. Today, if a pregnant woman do not receive food, then obviously, you know, this reason for the anime can also malnutrition is also very common. And it was also the same the role of the private pharmacy. Unfortunately, in the remote deteriorate in Afghanistan heaven if you go to today, people are selling medicine in their shops, bake shops in the same shop. You will also see medicine. You will also see vicious. He's also selling meat in the same bake shop. Some others are selling, you know, clothes, some other are selling, you know, vegetables, soup, you know, fruit. So there is a. It's a cult traditionally classic, you know, supermarket. And I found that so the community that when we are also getting medicine from this particular shops with the pregnant woman is dying, you know, and we don't understand, you know, what is the problem. So when I went to that one, you know, together with our team, we found that some of like they were selling medicine with their color, for example, patients when they were coming, you know, to the clinics. So they were asking to the, to their private, you know, shop, traditional shop where they were selling medicine, they were asking, can you give me tablets, you know, with red color? So the tablet with red colors was coming, you know, 10 years back that was kind of painkiller. But during last seven years that was antibiotic. So again getting, you know, antibiotics for pregnant women as a painkiller medicine. So that was another reason, you know, for those high level of child mortality and also maternal mortality. And then we also found then what we did. I think it was very interesting, you know, what we did. We develop a kind of local context package together with the health facility. When they asked discuss that we don't have place, you know, attached to the clinic, you know, for the worship. We spoke with the community and we told them, well, let's come and build two room attached to the clinic because, you know, there should be also a community contribution if it's coming to the religious sport. So the health system was funded by the international community. So and also from the international community. We had no budget, no authority to use, you know, for the. To build a mosque. So we spoke with the community, we told them, well, come build two rooms attached to the clinic. And during the day we were using that one for the health education. And then brilliant. We also asked, you know, the religious scholars and we train them, we tell them how important is also help from the religious perspective. So that that was another interesting thing. So there was a kind of real community engagements and religious engagement hall. So during the day we were using for health education, 12 o', clock, 1 o', clock, you know, in the afternoon, evening for the pray during the night for those pregnant women that they were coming from a very remote area. They were also spending, you know, night in that two rooms. You know, one room was for men, the other was for female. And we were used, call it, you know, like maternity waiting room. So maternity waiting room then for mosque for health education. And you will not imagine how much we spend all that $110, I think because only in the opening ceremony of those building, when that was completed by the community, we just gave them a kind of sweet and then small things for the pyramid and then I think that was something that we learned many things from that one. And then it was the same when I spoke with the religious scholar that how much money you are also getting, you know, from those pregnant women to provide them a kind of religious treatment. And he was telling me, well, we are getting, you know, $1. We told him, well, we will also pay you $1 when you receive any kind of complicated mothers in any kind of complicated, you know, mothers with complicated disease or children with a complicated disease, give us a missed call, we will send you an ambulance. We will also give you one balance. So in fact, you know, the religious scholar was getting $2, one from the patient and also one from us. But they were playing an important role, you know, referring most of those complicated cases to our clinic. And it also happened the same. We spoke also with the private, with the private pharmacy. We told them, whenever you are having any kind of mothers or children with a complication, health complication, refer those cases to us how much you are getting, you know, when you sell, you know, those medicine on them. So they were telling me roughly $1. We told them, well, we will also pay $1. So this project was mainly like, connected through $1. So $1 and a 1. We were paying also the same when I we spoke also with the traditional birthday attendant, those old women traditionally trained that they were playing important roles in the delivery. So when we spoke with them, so she was also telling me, well, roughly, we are taking, you know, $1 from the community to conduct that delivery. And we told them, well, we will also pay $1, bring all those pregnant women and our midwife, under your supervision, will conduct the delivery at the health facility level, at the clinical level. And then so most of those pregnant women that they were losing, you know, their life because of the complication at the community level, because of the high infection. So we prevented that one by referring most of those cases, you know, from the community to the health facility level. And then what important things we started. We also started community among ambulances. We give the number of ambulance to all those community influencers, influential people, you know, like religious scholars, those private pharmacies that people were getting, you know, medicine from them, traditional healer and then traditional birth attendants. And we told them that, well, when you see any kind of complicated cases, give us just missed call. So when to the missed call to the ambulances. So whenever the ambulance receive an Ms. Call, they will call you back and they will speak to you. So when we receive those patients, at the end of the day, your name will be registered and you will be getting also $1 per referral. So through $1, we were in fact able, you know, to connect, you know, most of those cases that we were missing, you know, with the community, with the health facility level. And it was also even the same that we also started something else, you know, very important, you know, at the health facility level. In community level, we had community mapping. Community mapping means we were putting, you know, a number of family in a piece of papers in a different village and then how many houses are there, how many pregnant women are there? Because in Afghanistan and many developing countries, we are also having community health workers. So community health workers, in fact, in every village, but there is between 100 to 150 family. There is male and female, you know, so one health post. So in each help post we are having, you know, two health workers. One is male, the other is female. So so male and female. What they were doing, they were in fact putting all the census in their map that in this particular village, this is the number of pregnant women, this is the number of children under one, children under five, even TB suspected cases in those one. So after each three months to six months, they were like updating that data map. So at the community, then at the health facility level, at the clinical level, we had, you know, the number that the target in our area, for example, how many deliveries should be conducted, you know, in this month from that particular area. So at the end of each month, we were also checking, you know, the registration book of the clinic to see if we are really getting that number of people that are reflected also in their map showing the same number. If not, then we were giving, you know, that list of defaulter to the community health workers. And then community health workers were informing family that, well, this month you are supposed to go to the clinics because of those antenatal care visit because of those, let's say vaccine, because of family planning, because of several other targeted disease. So, but you have not been there. Please go. This is the message from the clinic. So even when they were not coming on the second month, then we were also having, you know, started a kind of community outreach. So where we, one midwife, one vaccine, doctors in nurse, they in an ambulance, they were going and also visiting those pregnant women and also even children that they have not received immunizations, vaccine services to see, to check also their, let's say, nutrition status, immunizations and even if there is any other complication that still children are also suffering from that one or maybe diarrheal disease or ago respiratory tract infections. And others. So with this we were able. And then they were doing, you know, even, you know, those providing those services at the community level in the house of those religious scholar, even in the mosque or school. So these, these were some of the approaches that we were in fact able, you know, to cover, you know, maybe 100% of those population that they were in the need of the services. In the beginning, we were only like waiting in at the health facility level, you know, the clinical doctors, they were just thinking that, well, we are only responsible to provide services if people come to the clinic. And we forgot those community engagement. And apart from that, there was also very interesting thing when I asked from the community leaders that which kind of language problem you are having in many part of the world, sometimes there is also local terminology. And then we are also having medical terminology in local terminology. And I exactly remember that thing when I asked, you know, from the patient that which part, which kind of health problem you are having? And she was telling me, I have chest pain. And the other was telling me, well, I have abdominal pain. Chest pain in abdominal pain in the local terminology. And three different area was using for each other. It was like in other way around. So chest pain was a kind of abdominal in another area and other area it was chest pain in the third one, you know, abdominal was using, you know, for the chest pain. So there was several others, you know, local terminology that really our doctors could not properly answer that one. And then we just identify this local hand terminologies, you know, that were very necessary also for the medical staff to understand in order to properly, you know, diagnose them for the diagnosis, prescription of proper medicine source. So that local terminology training also help us a lot to remove, you know, the distance in terms of communications between patients and also doctors and the other important things. Sometimes they were telling us, well, we don't want to see, you know, this white gown, because white gown is not very good in our culture. You know, we change, you know, the color of the gowns from white gown to gray gown. Because, well, the main concept of the hell tail or clinics or public health to provide services to the community that are acceptable to them. So no matter, you can change the color of the gowns. White gowns were gray gowns. And even the color of the clinics, they were not very happy to see the white colors. And then we even changed the color of the clinic so it was like painted with a gray color in order to be acceptable to the clinic. And apart from that, we also involve community in the planning of the clinics. We told them, well, these are the. Your clinics, so whatever you need, we will be more than happy, you know, to provide, you know, the service that you need. So if you think these are not necessary, then we will totally remove them. You know, like, it's a kind of giving ownership, you know, to the communities. And then that ownership always help us. And also to protect, you know, the clinics also, whenever there was a kind of security challenges, you know, militaries, operations in the area by those people that they were against the government, you know, against the international community. So community always help us when we really tell them that, well, we are here, you know, to support you.

That is great. Wow. I have so many notes I've been taking during this. First of all, that is, I just love the creativity and the innovation that you're able to bring to those kinds of challenges. And there is so oftentimes a problem with, like, not having an appreciation of community engagement and the fact that, you know, building, like, having rooms to be able to, you know, just the. The what in some sense might seem like a simple solution of adding a couple of rooms, but then that provides a place for prayer. It provides a place for women to stay that have gotten there over the night. It solves, you know, one. One solution can. One in one intervention can provide a variety of solutions to a variety of those kinds of problems. And then the whole economic aspect of it, of the. In some sense, probably, hopefully affordable, but, you know, you were kind of enrolling people as, you know, triage experts to be able to, you know, get people to you and get people to you promptly. And again, this whole engagement aspect of what's motivating to the people that if it. If we have this problem that exists today, what can be done internally, respectfully, and some, you know, economically and somewhat creatively to be able to do that. And there's so oftentimes, as you probably well know, just asking those simple questions, like going from a white gown or lab coat or whatever to the gray is brilliant. I mean, it's just those simple little kinds in some sense, simple kinds of things. But oftentimes there's such a hubris of who the providers are or who in charge to not stop and take a moment and be able to engage with those in the community and those they want to work with. So I just. I think that that's so creative. That's so brilliant. Thank you for sharing all that. That is, again, my tip of the hat and kudos to you. That's. That's wonderful. So were you still Were you involved there during the time of the COVID outbreak or had you left Afghanistan at that point?

I was, I. I was involved like I was providing a technical support to the Afghan government.

Okay.

Probably you have seen one of my open later, I think it was published in Arab News. And so there was also another direct, another open letter to the president of Afghanistan. And that was published in one of the Afghan's famous Afghans, you know, newspaper. You know, it was very strange. You know, what happened? What was the reason why I did that one? Let me tell you something about that one. I was following, you know, the Afghan Squid 19 response plan regularly. And usually I was coming, you know, to the media and I was discussing regularly with the media providing a kind of technical support to the Afghan government through media. I was even, I remember in one day I was in three different TV or different TV because in Afghanistan, number of TVs are more. I think it's more than we are having here in uk. So in that small country. So then what happened? I was following, you know, that one. And at some instance I was taught maybe the president of the country is not really following, you know, the media because he was the one who was taking, you know, the lead of the national response. He was the chairman of the National COVID 19 National Response Committee. And then I, when I found out, well, several things is like missing. We are missing, you know, more opportunities in Afghanistan. So then I wrote a kind of open letter, you know, at night to the President of Afghanistan. And that was published in one of the famous news paper in Kabul. And then it was very strange. The second day I was approached, you know, by the presidential office and they were telling me, well, the director is speaking to you in our culture. So the president means, you know, it's a kind of, if you translate it directly, it's like the general director is speaking to you. I thought maybe which general director? There are several general directors. And then I understood to tell that's the president. So the president appreciated that response, comprehensive, you know, later. And he was telling me, well, please send us, you know, the comprehensive plan. We will also try to adjust our and see how much also that could also reduce, you know, those opportunities that we are still missing, you know, and I mentioned clearly there that, well, some of the skill that we can convert challenges to opportunities so that later help us a lot. So based on that later, I think there was significant changes the leadership of the Ministry of Public Health. So some people were removed from their position. And then the National COVID 19 Response Plan was also revised, adopted and very contextualized, you know, so in every area and many it was not only, you know, the Minister of Public Health, you know, to be responsible, you know, so other line ministry was also were also included, you know, in this committee. And then we also thought, you know, that well, private sector is also one of the important component, you know, partners, you know, for the government. So private sector were involved representation of the private sectors, you know, many they were also involved part of that committee. And so this later helped us a lot. And then I was also asked well if I can also write maybe summarize that one and write it and send it to one of the English, you know, newspaper. And then I was approached, you know, by Arab News. I think they were based in Pakistan, you know, so they told me, well, can you write it, summarize it, you know, and 800 words, you know, we will be also able, you know, to publish that. So then I was very fortunate. That was also published in Arabic. So that helped a lot also in different area. Yeah, specifically those area that that was not totally included in the plan. And then we were missing and also some of the a people, some of these partner that they were really responsible to provide, you know, logistics support, technical support. But they were also not part of this national response committee, for example, who was responsible, you know, for the national, for the technical support. Unfortunately, in that initial plan they were not part of that national committee. UNICEF was responsible, you know, to provide logistical support also. And that was what they were also like. UNICEF was also not included in that one. So missing, missing, missing, missing and then blaming, you know, only the Minister of Public Health that they are not able, you know, to full fill, you know, some of the expectation of the community and the government, you know, so that was something, you know, like misunderstood and later help us a lot to be, to be make things, you know, very clear to everyone.

Yeah, it's, you know, it's. It's hard enough. I mean here, you know, I'm looking at it from a very jingoistic, you know, us based kind of perspective. And there's such, you know, complications and diversity and division and you know, the science hasn't caught up with, you know, how things mutate and you know, things change and it's a very, you know, fluid dynamic kind of thing. And I would just think it'd be so amplified with different languages and different kinds of circumstances and different levels of resources and things. So I can imagine that just trying to shepherd that and manage that and getting everybody kind of moving in the same direction is quite the challenge. So were you doing this? Were you already in the UK when this was happening or were you still in Afghanistan when this was these letters?

No, I was in Ukraine, I was in UK and I was also in one of the consulting position in Islamabad, Pakistan, you know, got it with one of the international organization. But still I was keeping my eyes also open, you know, on Afghanistan. Yeah, I was trying also to provide a kind of, you know, support in different way that I could also do it.

That's good. Well, and again, obviously it's, you know, it's been heard and it's been appreciated. So can you, I don't know how much, you know, I know very little about it. That's why I'm asking. But you know, how things are, you know, is there a Ministry of Public Health functioning now under Taliban rule? And do you know how things are going these days, just in general or in particular with COVID 19?

Well, I think the question is very important, you know, and I would be delighted, you know, to give a kind of overview, you know, what happened today and how that current, you know, responses could be also controlled. Unfortunately, like I mentioned, in the beginning, 75% of the Afghanistan health system budgets was dependent on foreign aid. Either, you know, US id, World bank or European Commissions. You know, we also had different small or big donors over 15 August, change in the local, in the government of Afghanistan. So the international community stopped their funding. So that also affected very significantly the health sector budget. So unfortunately, the current health system is just in the verge of collapse despite the fact that there is small, small support, commitment also from the United nations, some commitment also from these different, you know, government, uk, US government. So under the humanitarian support, the health system is also receiving, you know, some level of support, but not the same to maintain, you know, the operation of the health system as it was before the 15th of August. So and what we are also thinking, I discussed the same thing also at the Ministry of Foreign affairs in UK that well, if it is possible for the international community to go beyond the narrow scope of the humanitarian response in order to protect, you know, the investment of the last two decades, there are, there are enough, you know, investment in different sectors. A kind of foundation is there. But now, now with the scope of work of the humanitarian support, they are only providing, you know, a kind of, you know, life saving support. With this life saving support, you know, either if it is food or if it is something and also like medicine and also other. So with this we may not be able, you know, to protect the real investment. The real investment also need a kind of operational support.

Yeah.

And some support also for the maintenance. So our request from the international community is to be a little bit flexible people and to give, you know, more chance, you know, for those humanitarian organizations that they are working in Afghanistan to cover some of those operation and maintenance of the real foundation that we are having in different, you know, public sector, if it is Ministry of Public Health, if it is Kabul Municipality, if it is Cobbles, you know, if it is also higher education, Minister of Higher Education, Minister of Education, Minister of Public Affairs. So they need a kind of operational support budget for the operational and also for the maintenance. I know it will be very difficult for the international community to give that fund also to the Taliban while they are not recognized, you know, so they are not part of this, like a kind of recognized or legitimate government for the international community. So we are also thanking that as long as, you know, the international community is already involved in providing a kind of humanitarian support. So with exceptional or maybe with the expansion of some scope of work and to give more chance also to the international community to protect at least, you know, the investment by providing, you know, a kind of operational and maintenance support and give that chance also to the humanitarian organization to cover that one as well. So this will help us. Maybe with 10% of the maintenance cost, we will be able to protect 90% of those investment was done, also supported also with the international community during the last two decades.

I think that's a good point. I read that. And this gets well beyond my appreciation of how the mechanics of all this works, but that the U.S. treasury Department issued, started issuing recently special licenses so that some of the international aid could flow back into Afghanistan. And I would hope that that could be foundational to what you're talking about, about getting those things put back into place and operational, because it is. It's so systemic. I mean, any one area that's overemphasized creates a deficit in the other. And any deficit in any area can conspire to just make things horrible. And I would imagine, I mean, it's sort of an irony to me, being a kind of a data nerd. And I appreciate that you maybe share that as well, too, in terms of epidemiology. But I would imagine too that we're going to see, unfortunately, probably some weaknesses back with maternal and child mortality and morbidity. We're probably going to see a variety of things ripple over the course of the next few years and some weakening of programs just because they can't be sustainable without that kind of support. But do you foresee there's any kind of epidemiological surveillance or anything like that that we keep an eye on these kinds of things of morbidity and mortality or maternal health or some of the things that you've been involved in historically?

I think it's very important, you know. So let me answer this question in a different, from different aspect.

Okay.

First, the impact of the current humanitarian crisis immediately and also in midterm on the western world, including us, Ukraine, the whole regional world. So the whole world will not be protected if the current humanitarian crisis go the way that it's going on unfortunately today. So from three different perspectives. First, as you mentioned, you know, this Afghanistan is unfortunately having, you know, an estimated 12,000 HIV positive cases. With this 12,000, we were only able, you know, to say, to diagnose around 3000, roughly 3000 positive cases. Out of this 3000, only around 1200 register for the treatment. So the remaining are just in the community. And we also have different level of services, like harm reduction services which play an important role to control, you know, the prevalence of the expansion of the number of hiv. So now we are not having that kind of humanitarian, sorry, these harm reduction services and even the registered patient for the treatment hiv, they are also not receiving regular medicine. So that could be another factor that suddenly the number of HIV cases in the country will be increased. And when people are also coming out of Afghanistan, they could also easily transfer those cases also to the other part of the world. Second one, in Afghanistan we also have multi TB drug resistant cases. There are so many cases of positive TB that they are resistance against the medicine. So that number is also in very high number. I think it's 2,500 cases. So that, so today those already diagnosed MDR cases, multi drug resistant TB cases, they are also not receiving, you know, medicine. And so that could also give chance to spread, you know, those infected TB cases resistant with drugs. And apart from that, that the current positive TB cases, let's say it could be around 10,000. So this 10,000, they are also not receiving regularly medicine. So if when patients are not receiving, you know, regularly, even their TB medicine, that could be converted, you know, with this multi drug resistant tb. And that is why Afghanistan could be a happy center. And also for this several infectious diseases, the Same also for COVID 19. Unfortunately, unfortunately, the coverage of the vaccine in Afghanistan for Kuwait is also very low. We don't have proper diagnostic services, we don't have proper treatment center in Afghanistan. And it is also the same. Nobody is taking care of those preventive measures. WJ is also saying that no one is safe until everyone is safe. Well, if we listen to the United nations, then if Afghanistan is not safe, then it means world is not safe. And I hope, you know, the international community could also pay attention to that one. I clearly discussed this one also with the American Public Health association president. I think, you know, just one, one and a half month back. And I clearly tell them, well, they can also make their noises in us that where Afghanistan could be a center, focal center also for many infectious diseases. And then people, when they are also going to us in UK or maybe different part of the world, could easily transfer most of those infectious disease because it's spreadable, you know, so they can easily spread it.

Right.

And then coming back, you know, and then looking to the different other perspectives. So when Afghans are like, unfortunately these days they are suffering from starvation. You know, starvation is very common. 22 million people today, they need immediate humanitarian support.

Wow.

And we have been grateful for the United Nation in many countries that they are providing, you know, kind of humanitarian support. But these, this, these are not enough for the Afghan. So that's why today, if you follow the news, there are many Afghans, unfortunately, fleeing the country, going through illegal, you know, way, coming to Europe or going to other countries through illegal. So that could also destabilize, you know, the countries. Because when these people come here, you know, illegally, so either they are losing, you know, their life in the way or creating, you know, security problem for country. And the last important things, we are also having, well, million Afghans. I think it should be millions now. Millions. Afghan diaspora in us, UK and many countries now, we are also having a kind of mental problem, stress, depression. Because every day I'm receiving a message from Afghanistan that while my families, my kids are dying because we don't have enough food, so that increasing level of mental disorders, let's say kind of depressions, anxiety, everyone could cause some kind of, you know, suicide here in uk, US and also other part of the country, because if some part of their family is dying in Afghanistan. So listening every day that messages that my family is dying, please help me. And then sometimes they may not be able, you know, to provide them enough support. So that could cause, you know, maybe very high load of, you know, those mental, mental health, you know, challenges in the country and complication of mental health is, you know, sometimes it's very clear, could cause also even, you know, suicide in different part of the world.

Wow.

So that's why we are thinking that, well, the international community at least could provide, you know, enough support to the Afghan inside Afghanistan at least, you know, to prevent, to, to protect also their country also from this negative impact that I already mentioned.

Yeah, it really, I think it speaks, you make a variety of very poignant points and it speaks to the, not just globalization, but just the interconnectedness of all these kinds of things. And indeed, the humanitarian crisis has not ended in some ways. I think it's obviously being amplified with the current circumstances. You, you wrote in a recent article I read in the Lancet that was published in the Lancet with some colleagues around these kinds of issues of the humanitarian crisis and urgent health needs and things. I think it's, you know, I tip my hat to you again for this and doing that and bringing it out there. But what spurred you and your colleagues to write this? Just to be able to, you know, you found good, like, once there's a, you know, people that listen and media that hears things to get this. But then, you know, the Lancet's a, you know, fairly, you know, scientifically focused audience, highly respected, one of the top journals, I think, in the world. But what spurred you to write that and what did you hope to have happen as a result of that?

I think there was three main reasons. First, I knew, you know, the level of the international support in Afghanistan. So if international support stop in Afghanistan, what would happen? You know, so this level of humanitarian crisis that we are having today, we projected at once, even on the first day of the 15th of August. So that's why my first interview was, was with the Guardian Night of 16th of August, that what will happen, how much, you know, it will create, you know, problem to the Afghans, to the community, to the international communities, you know, what will be the level of this humanitarian crisis, you know, why we will be having humanitarian crisis with this change. And so, and then I was also approached, I think, you know, by almost all media in Europe, Europe in US and so they were also very happy because when they saw, you know, that interview published in Guardian on 16th of August, just few hours after, you know, the collapse. And so then this was one site in second one, I was also daily receiving, you know, messages, you know, from Afghanistan and that, well, the country is just going, you know, to be in a very difficult situation. So we need to inform, you know, the international community. So those kind of messages, pressure also from colleagues, friends in Afghanistan. And then my level of understanding, you know, from these financials, mechanism funded of the Afghan government fund it, you know, with a huge support from the international community. So this one and then we, I have been also very grateful, you know, for the international colleagues in different part of the world when they were also, like watching the, the interviews, you know, reading, you know, some news in different newspapers. So they were also encouraged, you know, they pushed me, let's come and also write a kind of article. So the first article that we published, I think it was the first one, first week that we published in Lancet, and then we also did an interview with the Lancet, it was a kind of podcast, and then another article at the British Medical Journal. And so still I was contributing in many other discussion, different part of the world, you know, at least to see how much we can also reduce the level of stress, tensions, level of humanitarian crisis in Afghanistan with the support of the international community. We have been really grateful, you know, for the support of the United nations, different, you know, Western countries, including uk, US but still, that level of support that we, our people are receiving in the crowd is not enough. And we unfortunately, just today that I'm discussing with you, over 1 million children are just starving and over 1 million children are just in the risk of dying. And every day children are dying in Afghanistan because they don't have access to food. So I think that message needs to be clarified to the world as well. And then unfortunately, very unfortunately, the de facto authorities in the ground, sometimes they are also not sharing, you know, the real challenges of the Afghans. You know, they think, well, if we share, you know, the challenges, then the world will not recognize us. Recognition of the local, you know, authority is not our interest. Our main interest is also to protect our people, to see, you know, Afghanistan, I guess, again, you know, happy Afghanistan, fresh Afghanistan, bright with the bright futures, you know, to see how we can also get, you know, chance that those Afghans, that they are leaving today, Afghanistan or return. But the biggest challenge in the history of the country that we are having today, it is brain drain. I know many people, unfortunately, most of those people educated in the Western world during the last two decades are either they already left or they are leaving. So this was, you know, the main brand, you know, like human resources, that they were playing important role. And if you remove all those skillful people, educated peoples, understanding, you know, the world, understanding, you know, the technology, how to use them, you know, how to develop, you know, like how to develop, you know, money system also in the country. And these were the main people, you know, used, you know, for the operations of the current system. So this, and just to assure you, once people left the country and they settle somewhere, it will be very difficult for them to convince them to, to go back to Afghanistan. So that's why our expectation from the international community is also to provide enough support and hire also those people that they are still in the country through those international organizations that they are providing, you know, different level of support and to create a kind of job for them and protect them. And so with their protections, you know, if Afghanistan is safe, the world will be safe. If it is not safe, then we remember, you know, the story of, of 9 11.

Yeah. Yeah.

So I, I, I, I, I'm scared that maybe that will again, you know, happen.

Yeah.

Because the world is unfortunately in very, unfortunately not paying, you know, full attention, you know, to the Afghan, to Afghanistan, you know, to protect and also those negative impact also on the world and also inside Afghanistan.

Yeah, good points. All right, well, this has been really a wonderful conversation. I have just a couple of other things if you're good for time. Great, Great. In doing my research, am I correct in thinking that you may have a book in the works? Is that right?

I am working, yes. I'm working on a very interesting book that was also in light of those innovation that I had also in the, the health system in Afghanistan, you know, this area. Yes, yes, yes. So the book is also very interesting, you know, so it is like, you know, why innovation is very important in rural development. So without innovation, we may not be able, you know, to see, you know, most of in most country, rural area, you know, to have a kind of balanced development. And it was very interesting because in many developing countries, unfortunately there is no balance development, you know, because of different reason either political city, like, you know, the budget they are, they are allocating also for different provinces, different cities are influenced also by the politician. So if you don't have strong politician, you may not be able, you know, if you are living in a very remote area, enough budget for their development. And second thing, human resources are different. You know, sometimes if you allocate, you know, equal budget to them, so, and even equal budget could not produce equal development because of the lack of resources there, you know, food resources and lack of, you know, and fast, you know, lack of awareness about the public service, you know, good stuff. So, so my role is also to, I hope, you know, I will be able to complete this book in next one and a half year because it's very comprehensive book and I hope that I will be able to speak with you once we latch the, you've got a deal.

I think that would be great. I just, I feel like a lot of the issues you talk about, it would be great to have it in a book. I mean you've, you've taken a very scientific research aspect and look at looking at it in terms of, you know, identifying problems and trying solutions and seeing the effect of those solutions. And I've had, as you were talking about it, it made me think of like I was doing some work years and years ago in South Africa and we were working collaboratively with traditional healers. And in South Africa, if memory serves, there's like a 20 different national languages. So it was sort of like this just Tower of Babel trying to get people to properly communicate and making sure that I loved your point about chest pain and stuff about how that can be. Someone might think that's just universal and specific and. No, it's not. Or the red pill and how that's changed. I think those kinds of stories kind of really bring to light an eye opening kind of experience for healthcare providers and people in medical training and supervisors and things. So I think your book would be a welcome tome to be able to help do those kind of creative things in rural and resource poor kinds of areas so well. Again, you've been so generous with your time today. Are there some ways that people in the audience, interested listeners, can be of help or learn more about your work or what are good ways? I know that you and I connected via LinkedIn, but if people want to know more about what you're up to or provide some kind of support, what are good ways to do that?

Well, thank you very much for this opportunity that at least, you know, I can also share, you know, some of my lesson learn and also learn also from the audience. And I'm sure, you know, once you share that podcast, there will be also some sort of feedback and also from the people, you know, from the audience, respected audience. Yeah. So through that we will be also I will also personally learning a lot of stuff on them and I'm definitely sure. So I thankfully I what I'm thinking let's open the other discussion know for the audience.

Okay.

When we are also they are hearing, you know, the podcast and I'm sure they will be putting a lot of question and I will be more than happy, you know, to provide, you know, to connect it also with the audience to see in which level, you know, we can also help each other because it's a globalization, you know, so the world is like a small village now.

That's Very.

So in the small village, what we need to be connected.

Got it.

So network is important, you know, we need to share, you know, the good messages, at least, you know, very helpful messages with each other that we learn from each other. And otherwise it would have not been possible for me to come a child growing, you know, up, you know, in a refugees camp selling waters. And then when I got, you know, kind of promotion, then I started selling vegetable in fruit and was not able to have, you know, sandal for very long time, you know, Sorry, sorry. Shoes for a long time wearing, you know, sandal. So this would have not been possible for me to come here without network. I think network is always helping us. So this was the feedback of colleagues, friends, everybody to encourage me also to help me, to support me during different project, you know, that I reach here. And this is for me it's like a kind of beginning of the journey. So my future journey will be broader because I learned a lot from my lesson, from my work, you know, during the last two decades and also from those education. So as you mentioned that I'm leisure at the University of London, so we'll be moving, you know, to Cambridge where I can also learn, you know, new things from the universities, professors, peers, colleagues and from students, you know, because that university is one of the best university in the world.

I congratulations again by the way. That was. I didn't emphasize that enough. That's wonderful. That is so wonderful.

Yeah, well, thank you very much. I think let's leave, you know, this questions maybe to the audience.

Okay.

Having any things so we can stay together. And maybe in the future we can also come again, you know, to record a different podcast.

I would love to have you on again for a round two. That would be great. And, and absolutely a lot of the sites that this conversation will show up on will be LinkedIn and will be Medium and will be YouTube, a variety and Facebook. We've got a group there, actually two different ones. This might be applicable for in academia, Edu and a number of other places where people can comment and engage with you. So I'll send you hopefully everyone, all the audience might have those links anyway they come out. But you can just google whatever your favorite source is of this show and Obviously you too, Dr. Hakmal, to be able to respond back to them and connect with them and be additive to the work that you're doing and do that networking that is so critical and important to this kind of work. I totally agree very full heartedly with that. So thank you again for the time. Appreciate the time difference and taking your time out of late in the day for you to be able to do this in the UK and I look forward to what comes next. Do let me know how the book goes and the work that you do is so important. And again, congratulations on the Cambridge appointment. Good to be on with you. Living a Life in Full is a production of Stout Media, a subsidiary of Gordian Knot, LLC. Assistant producer Gracie Wong Music Dan O' Brien executive producer and host Dr. Chris Stout to learn more, stop by our website at lifeinfull for show notes and please recommend us to your friends and subscribe on your favorite platform. And as for the obligatory disclaimer, this podcast is for general information use only and does not constitute the practice of psychology, medicine, nutrition or other professional health care services, including the giving of medical or psychological advice. No doctor patient relationship is formed. Lastly, and perhaps most importantly, I take conflicts of interest seriously. For all of my disclosures as well as show notes, please see livingalifeinfull.org podcast and my LinkedIn profile profile. Thanks and until next time.