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On the Front Line of Health Care in Afghanistan

After ten years working as a neuroscientist, David Royal ('10) decided it was time for a career change.

His search for a new career led him to the master's of science program at The Dartmouth Institute for Health Policy and Clinical Practice (TDI) and—ultimately—to the U.S. Navy. Now he’s putting his TDI education to use every day in Kabul, Afghanistan, where he is deputy chief of operations for the Office of Command Surgeon with the NATO training mission in Afghanistan. He recently took a few moments out of his grueling schedule to explain his work helping hospitals transition from being Coalition-led to Afghan-led.

What brought you to The Dartmouth Institute for Health Policy and Clinical Practice?

Before attending TDI, I was a neuroscientist at Vanderbilt’s Brain Institute. In 2009, I looked downrange and I decided that I was unwilling to make the necessary sacrifices and commitments to advance my career to the next level. That raised a number of questions for me, chief among them, if not neuroscience, then what? I wanted my work to have more immediate impact, and I wanted to work in a more dynamic environment. I surveyed my skillsets, and I married that list with my interests and settled on the generic-sounding “health-care management.” I spent months researching and comparing programs. What ultimately sold me on TDI was its reputation and the program’s one-year master’s program.

How did you end up in Afghanistan?

The answer is rooted in the answer to a larger question: “Why the military?” A few months after graduating from TDI, I was reflecting on why I left a successful career in neuroscience. I started to think about the person I’d become after working in the field for more than a decade. For the vast majority of that time, I was working mostly by myself in a small basement room illuminated only by computer monitors. Imagine spending years in social isolation—that was me. I chewed on the topic of my personal growth for a long time, and then it hit me how different I was from the kid who started his PhD in 1999. I realized that I had forgotten how to connect with people, how to work with people, and how to be a team player—“things I learned in kindergarten” kinds of things. Also, although I was essentially the head of a lab for a few years, my leadership skills had not developed one iota, largely because I didn’t feel connected with people. I realized that the person I’d become was ultimately self-limiting; I needed some course correction. My father was a career Navy man, which gave me a front-row seat to the benefits of military experience. Joining the Navy Reserves as a health-care administrator was a no-brainer. I’m happy to say that after four years of military experience, I’m finally feeling like my old self.

Can you describe what you are doing in your current post?

Royal outfitted in the gear he wears every day: multiple firearms and rounds of ammo, a bulletproof vest, a combat helmet, and a gaiter to prevent him from breathing in the toxic dust in the air.

As deputy chief of operations, it’s my job to help ensure that the wheels of everything medical in Afghanistan continue turning—from logistics to preventive medicine. We have lots of very talented people on the ground doing great work. I stay out of their way and focus on ensuring that their efforts are always aligned with the Coalition’s larger mission.

As the transition team lead, I ensure that all of the Coalition’s medical assets are properly transitioned to Afghan control according to the timetable set by Command. The Coalition helped the Afghans stabilize, equip, staff, and run a number of hospitals in the country. With our mission ending, we’ve slowly been transitioning control of these institutions to the Afghans and, instead, taking on a more advisory role.

I hold several other titles, too. As lead medical research advisor, I'm giving Afghan physicians guidance on how to set up and run Afghanistan's very first medical research program. It's a lot of work. I draw upon my PhD training and research experience. I also draw upon virtually everything learned while at TDI, including a few courses taught by Tuck School of Business faculty.

Additionally, I was appointed the lead statistics advisor for, effectively, all of Kabul's medical system.  The Afghans heard that the Command Surgeon had a statistics expert on staff, and before I knew it, I was crunching health-care data for various Afghan hospitals and health-care agencies. Now I meet weekly with various hospital staff to teach them how to collect the right kind of data and how to transform those data into actionable information. Again, it's a lot of work, but I really enjoy interacting with the local nationals.

How long have you been doing this work? Do you have an end date?

My military service began in 2010, and my contract with the Reserves ends in 2018. I’ve been on deployment in Afghanistan since December 2013. The exact date of my redeployment home is classified, but I’ll be home before the end of the year if my orders remain as they are currently written.

What are the biggest challenges in your work?

We’re putting our lives on the line every minute of every day. Potential threats are everywhere. Combine this with Afghanistan’s harsh environment (we’re always fighting dehydration at this high altitude; I sweat through my uniform on a typical day), our Spartan living conditions, and the long days, and I’d say the biggest challenge is fighting complacency and fatigue.

Apart from the challenges posed by the Taliban—and I have to laugh at this—my biggest personal challenge is taking care of my teeth. The water from the taps and showers here is non-potable, and whatever is in the water is wreaking havoc in my mouth. I’m currently saving up for the impending dental bill.

What keeps you inspired and committed to this work?

The knowledge that we’re accomplishing something good. We’re fighting for the safety and security of all of Afghanistan, and it is my hope that our efforts will continue to reap benefits for Afghanistan and beyond for decades to come.

How has your education at TDI prepared you for your current role?

It’s not an understatement to say that I draw upon everything learned while at TDI. You have to remember that Afghanistan’s health-care system is in its infancy. They had to start not that long ago from the ground floor. Everything I learned at TDI is applicable here. I use all of that experience every single day.