Tuesday, December 30, 2008

Christmas in Kabul

I had not smelled incense in awhile, so I was delighted when I saw on the makeshift altar at Christmas Eve mass the familiar censer. I hadn’t expected the priest here to travel with such an extensive array of liturgical implements. The sight reminded me of my Catholic grade school days when I served as an acolyte for parish funerals. Not only was I excused from class for the duties, but I got to prepare the hot coals that elicited the thick, fragrant smoke when the presiding priest spooned incense into censer after I brought it to the altar. In fifth grade, I was relieved of these duties when another acolyte and I set a rug ablaze just off the altar in the sacristy as we were a bit overzealous on the number of charcoal disks that we set to burning in the censer, and a few fragments of red hot charcoal fell to the rug. Even after that embarrassing fiasco, I still look forward to a mass with lots of smoke.

The first whiff of incense smelled wonderful on Christmas Eve, but then I noticed my throat felt even more irritated than usual, and I was suppressing a cough. Air quality in Kabul is poor at best, especially in the winter. Kabul sits in a valley surrounded by mountains, and when the chill air of winter arrives it restricts all the particulate matter floating over Kabul from moving anywhere. The poor population of Kabul burns anything to keep warm – wood, cardboard, tires, plastic – adding even more particles to the pollution. So the air often looks and smells toxic. We don’t help the situation at my base in the middle of Kabul as we have two barrels in which we openly burn all sensitive documents. What I realized was that the incense smoke at the mass, although it served as something of a comfort scent for me, was exacerbating the reactive airways disease I think I have developed the past few months.

Luckily for me, the good father presiding set the incense aside soon after the mass began, and I regained my comfort until it came time to kneel on the metal hut’s concrete floor. I really thought we’d just sit in our chairs during the periods of the mass when traditionally you kneel, as normally you aren’t expected to press your knees onto cold concrete. But perhaps it was appropriate that I mortified my flesh (specifically my patellae) in this manner while in Afghanistan, as the Afghan year is 1387, a date in the Christian calendar when such pursuits were more common.

The priest at this base is known for his scholarly approach to preaching, and he gave an interesting historical account of the origins of the day December 25 as the date Christians celebrate Christmas. In the first few centuries after the death of Jesus Christ, if Christians celebrated Christmas it typically was during the months of April or May. In fact, the birth of Jesus was not even a universal celebration among early Christians, who usually were too busy avoiding persecution to stage a birthday party. Eventually, though, once the Christians were able to worship somewhere other than a hidden cellar, Church leaders decided that the birth of Jesus should not only be a feast, but a celebration during the darkest time of the year, as Christians believe Jesus brought light to a dim world. There doesn’t seem to be a consensus among scholars as to why the date December 25 became the standard for Christmas, but the day does provide the requirement of being relatively dark (and cold, in many places, including Kabul), and also is a turning point in the season when light begins to fill more of our days. (I’m not sure what scholars have to say about present-day Christians residing in the southern hemisphere, who are able to adjust to Christmastide during their warmer months, just as they can tolerate the winter and summer Olympic games coming to them off-season.)

I thought as the priest spoke that my Christmas was not the darkest period of this year for me. That would have been the Thanksgiving holiday, when I was suffering through an extended layover at Bagram Air Field, the sordid details of which you can review in my two previous blog entry. In contrast to Thanksgiving, Christmas Day in Kabul was a jolly good time. The weather here was beautiful: sunny (with reduced smog) and temperatures in the low 50s Fahrenheit most of the day. The dining hall served the same meal for both lunch and supper, which didn’t bother me at all as it was similar to eating a large early dinner followed by leftovers in the evening, the tradition among my family. And the food was pretty good: freshly sliced roast beef, turkey, ham and all the traditional fixings. The only disappointment was the virgin eggnog.

My roommate, Matt, and I have been in the habit of playing horseshoes and smoking cigars every Friday afternoon, as that is our one day off each week. Until Christmas, I was undefeated in the pit, but unfortunately I missed a medal in the horseshoe tournament Matt organized for our office. That didn’t dampen my holiday spirit, however, as the entire base seemed more festive than usual, as is appropriate. Everyone has been enjoying treats and gifts from the innumerable care packages sent by friends and strangers alike. I’ve received everything from an indoor basketball hoops that plays stadium rock (“Na-na, na-na-na-na, Hey!”) to Asian shrimp crackers (a favorite of mine).

The Army also brought onto the base for the day two horses and two camels. A few people rode the camels, but most of us just took photographs with them and their Afghan handlers (one of whom was a boy no more than ten years old), or at most briefly sat atop one of them. A trip to Qatar and a local camel market there earlier this year taught me that camels are loud, smelly and obstreperous animals. The camels’ Christmas day appearance at my base confirmed that lesson. Those beasts do NOT like people sitting on them. They don’t even like people coming near them, it seems, as one camel spit at a friend of mine when she got close to it. Later in the day, at the horseshoe pit, after she told me that she was glad none of the spittle landed in her hair, I inspected her head and had to tell her that she was carrying around a few crusty streaks of dried camel saliva in her otherwise lustrous hair.

I avoided the horses, as I don’t know how to ride them and feared being thrown into the side of a metal Conex box should I attempt to navigate one of those animals through the base. I don’t think the United States military awards the Purple Heart medal for equine-induced traumatic brain injury sustained during leisure time in a war zone, and I envisioned a ride on a horse as producing nothing but pain and embarrassment. I did watch several other more daring folks ride the horses, a few of whom had impressive equestrian skills. However, the animals identified immediately the riders who hadn’t a clue what they were doing atop them, and those riders simply held on as the horses trotted and dashed according to the animals’ whim. One Afghan interpreter had a horse rearing back dangerously on its hind legs, and the smile on the Afghan’s face was really a grin of fear, as the horse appeared to be ready to buck him off the saddle. We notified the physician on duty that he should be ready for some unconscious people coming to him with closed-head injuries, but reportedly everyone walked safely away from their encounters with the animals.

When I told my niece Isabelle about the camels here for Christmas, she astutely noted that they would be more appropriate on Epiphany, the Christian celebration of the wise men arriving in Jerusalem on camels. She's correct, of course. In fact, I don't think camels are mentioned in the story of the Nativity until the wise men rolled into the Holy Land; but when I inquired at the command headquarters I was told that Tuesday, January 6, the Feast of the Epiphany, would be a normal working day.

Sunday, November 30, 2008

A Holiday to Forget: Part II

See previous blog entry for Part I

I am a fan of war movies, especially those films depicting soldiers in World War II as they sit around airfields and flight terminals waiting for their transportation to battle. I always assumed that such moments, as devised by Hollywood, paid true testament to the moments when soldiers bonded, when they solidified their camaraderie and fellowship; when banter was witty and biting and strangely intelligent, given the circumstances. After sitting with other uniformed personnel for several hours in an airport terminal on Thanksgiving morning, I learned that I had been mightily deluded by those scenes. Most of us that morning were tired, shrill, impenetrably absorbed in our own personal discomfort, slightly foul of odor, and unable to string two sentences together without a few F-bombs littering our grammar.

The movies often show soldiers in similar situations playing cards and throwing dice, the financial fin de siècle behavior brought on by war and the uncertainty of survival and return to the conventional existence of their homeland. None of that took place on Thanksgiving morning either, as the DoD has made it a point in America’s most recent wars to prohibit any vice that might provide measurable entertainment and relief to the troops. Besides, I am an officer and most of those willing to wager their salaries would have been enlisted. It isn’t proper that I gamble with them, especially if I am ready to take their money (which I would be). I admit that in the past I have ventured into a few low-stakes games of chance with younger enlisted personnel, and I have found them as a group to be rather reckless with their betting and unwilling to allow the odds to direct their wagering; and although I could rely on them for regular income, it’s best that I keep my distance, sort of like Vegas gamblers remain isolated (supposedly) from the athletes on whose performances they bet millions.

But gambling wasn’t forefront on my mind as I sat through my sixth hour at the terminal Thanksgiving morning. Instead, I was wondering when I would be able to get myself a bit of lunch. Thanksgiving is a holiday that prizes gluttony, and I had yet to take a bite of anything. Had I been at my mother’s house, I already would have eaten a large breakfast and most of the skin off the family turkey that sits freshly roasted and preening in the kitchen before the early afternoon feast. The instructions from our surly “flight coordinator,” however, were that we were not to leave the departure gate as we might be called to board an alternative flight at any moment. The reality of military travel is that often you will wait hours (if not days) for transportation, only to be given three minutes to board a plane or bus once the vehicle arrives; and if you are not present to board the craft due to an irresponsible absence brought on by attending to such trivial personal desires such as an urgent need to void or to procure a sandwich for your only meal of the day, the transportation simply leaves without you.

Finally, mercifully, at 12:30 – after 6 ½ hours of waiting for a flight – our surly “flight coordinator” confirmed that we had no transportation that Thanksgiving Day, and excused us with instructions to grab our luggage from the pallet on the flight line and return the following morning at 06:00. This time I remembered the advice often given surgery residents to help them survive their demanding clinical training regimen: Sleep when you can, eat when you can, make love when you can, and don’t f--- with the pancreas. General Order #1 forbids most sexual intercourse in theatre, and I had no intention of opening anyone’s belly to play with the potentially self-autolyzing organ that is the human pancreas; but I was very tired and I was very hungry, so I made my way to the transient billeting office anticipating a pleasant Thanksgiving nap followed by a proper holiday meal. I had no intention of hauling both a backpack and my large duffle bag around that day and early the next morning; so I removed my sleeping bag from the duffle and left the remainder of my belongings under a tent outside the terminal, thinking that I likely would retrieve them the next morning, but not really concerned that my government-issued winter gear might disappear overnight. I looked like a sad, green, slightly underweight, hang-dog Santa Claus as I walked to the billeting office with the unfurled sleeping bag hanging over my shoulder, a few items for the night lending it only the slightest girth.

Even though I had logged only a minimum of intermittent and fitful sleep the past thirty hours, I opted for a Dairy Queen mushroom cheeseburger before I passed out, as I imagined in horror that I might sleep through the base dining hours and awaken late at night famished and without any meal options. (Those who know me well know that my greatest fear is not poverty or death, but sustained hunger.) I also remembered the advice for the budding surgeons: Eat when you can. Some of you might be surprised to learn that American fast food chains such as Diary Queen have outlets on bases in Afghanistan. Let me assure you that these restaurants – usually trailers painted with the familiar chain symbols and logos – often are similar in name only to their counterparts found on US soil. One Pizza Hut I recently visited offered mozzarella that tasted like fish; and the Dairy Queen near my tent produced a burger smothered in an herbed cheese with the consistency and taste of Elmer’s glue mixed with horseradish. The cheese concoction, when it dripped off my burger, literally bonded together several of my French fries.

The dreadful meal at least provided the sustenance for which my body, very unaccustomed to fewer than four meals per day, had been crying since early in the morning. The beef and fried potato glue ball in my stomach also absorbed the last bit of energy I possessed that afternoon, and I crawled into my winter weight sleeping bag without realizing until I awoke a few hours later that the temperature of the tent approached 95° F. When I suddenly found myself conscious but simmering in a profuse sweat, I thought that perhaps one of the low-flying jets overhead had released fuel on me and my tent mates. I realized quickly, however, that I smelled like the mat from a summer wrestling camp, not a gas pump; and only then did I notice the hot breeze circulating within the tent. The roasting air which had turned the tent into the world’s largest convection oven emanated from two cylinders, one at each end of the rectangular tent, that were almost two feet in diameter and reminded me of the spouts of the snow machines found at ski resorts; although instead of spewing frozen precipitation, these pipes belched heat.

Of course I had not brought a towel with me to the transient tent, or any other implement suitable for mopping the sweat off myself, so I stepped outside in my boxer shorts and prayed the cold, dry Afghan air would evaporate the solid sheen of perspiration I was carrying before it froze into an ice casing. Because women and other horrified personnel walked by the tent, I couldn’t stand outside barely covered for long. So I went back inside, recalled that it was Thanksgiving Day, confirmed that it was dinner time and a holiday meal awaited me at a base dining facility, and slipped my uniform over my still moist frame. As I made my way to the turkey, I stopped at a latrine trailer and dried with paper towels what skin I could reach underneath my uniform.

I must have been in a foul mood, or simply lacking the appropriate holiday spirit, because I have to report that I found the façade of a Thanksgiving meal and celebration constructed by KBR, the food contractor, both depressing and irritating. The turkey offered was the same processed variety we see weekly, with curiously identical slices segregated only by light or dark meat. I instead opted for a slice of beef called Steamship Round, which was a Chevy-sized chunk of meat impaled with a large bone. It looked very similar to what I often encounter when I lunch with Afghans, except the Steamship was much larger than the “leg of something” that the Afghans typically serve. It tasted similar, however. The dining room was littered with paper Thanksgiving decorations that gave the entire facility the aura of a very large elementary school cafeteria. A five-piece brass band played such festive holiday tunes as “Hold That Tiger” and “Get Back (to Where You Once Belonged).” I like to engorge myself with hot buttered rolls on Thanksgiving, but I was unable to do that as I couldn’t find the rolls and KBR makes only margarine available.

Probably my fatigue and sour mood fouled the meal more than anything KBR prepared. My repast was certainly the smallest, fastest Thanksgiving dinner I have ever eaten. I really wanted more sleep at that early evening hour anyway, so left the dining hall armed with a couple of cups of ice that I thought I might need later, and returned to my cot in the broiler that was my quarters for more sleep, very pleased that such a festive holiday was almost over.

Saturday, November 29, 2008

A Holiday to Forget: Part I

I now consider myself a seasoned military traveler in Afghanistan, accustomed to the delays, inconveniences and mysteries inherent to flight schedules in a war zone. So I take full responsibility for the frustration I encountered when I tried to travel via air on the Thanksgiving holiday. I was expecting too much. I was suffering under the illusion that the local airlift command worked toward the goal of transporting passengers with a minimum of pain and suffering.

My travail began the day prior to Thanksgiving, when I left my base at 05:45, arrived at the airfield at 07:00, learned that my flight plan would be available at 10:30, and finally confirmed mid-morning that my travel was not scheduled to begin until the next morning when I was expected at the terminal at 06:00. At that point, more than 18 hours before I needed to report back for my flight, I should have simply trudged up the street three hundred yards to the transient housing office, where I would have been assigned a cot in the transient passenger tent located almost one mile from the terminal.

A night in the transient tent did not seem too appealing to me at the time for several reasons. That morning when I would have checked in for a cot, I could have utilized the convenient base shuttle to take me and nearly door-to-tent; but the following morning, when I was expected at the terminal before sunrise, the shuttle would not yet be running. I would then have to wrap my duffels about myself and hump (as the infantry says) the entire distance, negating any hygienic advantage a pre-flight shower might have brought me.

Additionally, I try always to follow the advice of my college roommate Mike Monticello who admonished me to “travel heavy” whenever possible. Mike, while an undergraduate, owned what I think was the last produced steamer trunk from Brooks Brothers into which he carefully folded his cotton and linen wardrobe for trips as brief as an overnight stay at his parents’ place ninety miles away. I often pay tribute to Mike when I travel by loading my bags with whatever I might possibly need, to include a laptop computer, bottled water, several notebooks, a few hardcover medical reference books, a selection of exercise gear, sundry laundry products … More than once I’ve been able to offer assistance to a friend – who had ridiculed me earlier for over packing – by providing Internet wireless access, a chapter from Harrison’s Internal Medicine, and a shot of fabric softener.

I also had less than fond memories of the last time I attempted to sleep in the transient tent, which is located at the runway terminus for the busy airfield. Permanent housing for airbase personnel surrounds the transient tent, and I’m not sure how those military personnel adapt to sleeping through the noise as all night long the pilots of F-16 and Prowler jets ignite the afterburners for their craft at the end of the runway, before they are even airborne, to get speed and gain a safe altitude quickly (up and away from any enemy ground fire). The sound of this maneuver for a newcomer attempting slumber in the transient tent simulates a locomotive barreling through the canvas and overhead of the exhausted recumbent. (I recently learned from an aviation crew member that the Prowler, surely the most inappropriately named acquisition in the history of modern warfare production, is the louder of the two craft.)

Instead of a night in the transient tent, I opted to lounge in the USO building located just across the street from the terminal and open throughout the night. I figured I would be able to nap there, and even use the half-day to send one or two emails utilizing the world’s slowest wireless internet service that the USO offers. After all, I had my laptop. The USO, I learned, is comfortable, but only for brief periods of time. The facility caters to the younger military troops, as well it should, which means that loud Hollywood action flicks blare throughout the building day and night, as do large screen video game devices strategically placed to foil any attempt by a patron to read a book or even converse with a neighbor. The chairs look inviting, but I found they were not designed to support comfortably a forty-two year old spine. Also, once you sunk into the soft cushions, you found yourself immersed in the lingering musky vapors of seven years of US infantry who have transited through the airfield.

I have spent more than twenty-four straight hours on duty at a hospital, and I am a field grade officer in the United States military, so I was able in the early morning to ignore my fatigue, brush my teeth, wash and shave my face, and then report to the terminal at 06:00 ready for my flight. My plan was to sleep on the plane, which I figured we would load by 08:00 at the latest. I didn’t bother scrounging breakfast anywhere, as I deluded myself into believing that lunch would surely be available shortly after noon, when I expected to be at my destination. At 09:30, though, I found myself still cordoned at a departing gate with 60-70 other passengers, wondering just what the hell was going on with our flight; and if anyone in the terminal was prepared to give us any information on when we might be allowed to leave the terminal, either via the runway or the entrance door.

About that time a gate attendant brought in several boxes of Pop Tarts and breakfast cereal (without any milk), a courtesy that is in fact a terrible prognostic indicator for a military traveler hoping to move from his present location. And shortly after the improvised Continental fare landed on the dusty concrete of the departure gate floor, we got word from our surly “flight coordinator” (who had been not-so-mysteriously absent the previous 2 ½ hours) that our plane had been grounded due to mechanical problems, but that she was trying to locate another craft for our journey. She gave us this holiday news in a clipped, imperious tone as if we were inconveniencing her. It was typical of the military customer service approach, for which I will suggest to the Department of Defense adopt the motto “How can we not help you?”

Part Two of a "Holiday to Forget" coming very soon (like tomorrow).

Wednesday, November 12, 2008

Problems with Procurement

Many practitioners of modern medicine are quick to describe physicians and other healthcare “providers” as much more than simply skilled technicians able to manipulate human physiology with interventions that bring cure to maladies and injury. Some of us wish to retain the appellation of “healer,” signifying a more holistic approach to medicine that considers the patient’s entire state of good health, and not merely the absence of disease, as the therapeutic target. I agree that the ultimate goal of health is truly wellness, but I also know that I and most other physicians I know are really trained manipulators; and unless we consider ourselves faith healers, we aren’t very good at our jobs if we don’t have a considerable arsenal of pharmaceuticals, prosthetics, surgical screws and laboratory tests available for diagnosis and treatment. (I have yet to meet an internist able to reduce blood pressure significantly with conversation and meditation; or a surgeon successful in staunching internal bleeding with prayer and hypnosis.)

Few physicians in Afghanistan have access to even a fraction of the array of goods that an American physician relies upon for practicing medicine, a dearth that severely limits the care that competent Afghan physicians are able to offer. Even the influx of US government dollars does not solve the problem of scarce material resources for care here. Almost every component of Afghan society decayed and fell apart over the last forty years, including the commercial sector. You might have the money to buy laboratory reagents from the United Arab Emirates or a European supplier, but there is no reliable refrigerated transportation service in Afghanistan. In fact, those supplies, necessary for any modern hospital to support clinical diagnoses and treatment, might not ever make it through Afghan customs, even if they reach the border of the country. For a few weeks a colleague has been trying to determine if a cache of laboratory reagents is sitting unaccounted for – and likely spoiling – in a customs’ warehouse in Kabul or at a border station with Pakistan. Or if the supplies simply disappeared somewhere between the manufacturer’s warehouse and the designated Afghan hospitals.

The shipment might have been high jacked coming through Pakistan. The AP reported today that gunmen along the Khyber Pass attacked a convoy of trucks carrying “military vehicles and other supplies” (lab reagents?) destined for US forces in Afghanistan. I’m sure the bandits who pulled the heist are thrilled with the Humvees and trucks they captured; but if they took the time to examine the rest of the booty on the convoy and discovered vials of chemicals used to determine blood cholesterol levels and hundreds of urine pregnancy kits, they likely chucked these items into a Tora Bora ditch.

If the supplies you order do make it into the country, you have to be careful about how you distribute them. Highway banditry is the rule in Afghanistan, even moreso than in Pakistan. Local truck drivers typically consider every major roadway in Afghanistan a toll road, with the fare calculated and extracted from whatever goods comprise their loads. It’s a system similar to what the Mob ran at JFK Airport for years, and highlighted in the movie Goodfellas. So you should assume a rather high percentage of cargo loss if you send out a convoy of supplies to traverse Afghanistan.

Sometimes you can arrange direct delivery of supplies to a district hospital or clinic through a nearby airport, but you then risk incomplete accounting from the hospital personnel in the regions far from Kabul, as those folks just might pilfer a pallet or two of goods from the delivery and then report to the central accounting agency in Kabul that certain supplies never arrived.

The Recurrent Problem with Local Vendors

The United States government has a policy that American military personnel utilize local vendors when possible to secure the supplies we need in order to operate hospitals and clinics. The rule is reasonable, with the rationale that bolstering local Afghan businesses will boost the overall Afghan economy. Considering the prices many of these local vendors, who are cognizant of the US government rule favoring them as procurement agents, the American taxpayer is boosting certain sectors of the Afghan economy quite nicely. I have seen medical products of such low-quality and high-price that they would make even the most unscrupulous US military contractor blush with shame: flimsy nasopharyngeal airway tubes for $30, plastic catheters for $20, malleable arm splints for $60. And that’s the cheap stuff. I’m not sure how much x-ray film and surgical screws cost here, but the price tags would surely rival the infamous $400 hammer and $600 toilet seat that the Pentagon purchased in the 80s.

We may not be exporting stellar business ethics to the Afghans, but we are certainly developing an entrepreneurial spirit among the commercially aggressive men angling for whatever US business exists wherever they can find it. Builders, suppliers and vendors here often will promise that they can construct or deliver anything you require, regardless if they have ever contracted for the service or material before. I have seen business cards that read “Provider of medical equipment, and building foundation construction experts,” and “Shipping all your business supplies, with pharmaceuticals, and superior auto service.” Think that a US agency needs another service that you might be able to provide? Simply add that “specialty” to your business card, bid for the contract, and worry about delivering what you promised after you are chosen for the job.

Many of the Afghan businesses are experienced and honest with respect to their abilities, but contracting and quality problems arise far too frequently with local businesses. A medical technician’s school, funded by the US military, ordered through a local vendor a mannequin to teach resuscitation techniques, and a few different skeletons for anatomy instruction. The Afghan vendor assured the school that he could produce quality goods. The resuscitation mannequin delivered was simply a doll’s head. One of the instructional skeletons was similar to the paper decorations that litter most elementary schools before Halloween. Another skeleton was a poster with detailed anatomical references such as “upper leg bone.” A few of us joked that, for surgical instruction, we should order the game “Operation.”

Last month an order of more than $1 million in desperately needed pharmaceuticals finally reached a Kabul hospital. When the US agent responsible for the purchase went to inspect the shipment, he found that the local vendor had substituted cheaper drugs of dubious quality from China and Pakistan for the order, even though the contract specified pharmaceuticals only from reputable manufacturers in the United States and Europe. The Afghan quality assurance agent at the hospital happens to be a friend of the vendor, and appeared willing to stock the pharmacy with the inferior goods, almost certainly after a nice bribe from his buddy. If the US agent hadn’t caught the fraud, patients would have been exposed to poor quality therapeutics and the vendor would have made a profit considerably higher than the windfall he already was assured had he adhered to the contract.

An Afghan proverb translates into something like “If you wait 100 years for your revenge, you have moved too quickly to exact your just retribution.” The Afghan mind still puzzles me; and I don’t fully understand the adage as the average life expectancy in Afghanistan falls somewhere in the mid-40s. I only hope that the average Afghan, who would be happy with a modicum of modern medical intervention, doesn’t have to wait much longer for a little bit of healthcare and a national business ethic that isn’t grounded in thievery.

Friday, October 31, 2008

Critically Ill: Afghanistan's Healthcare System (Part Three)

This is the third and final article illustrating several of the challenges encountered in building a functioning healthcare system in Afghanistan.

Hopefully your village has a medical clinic, and hopefully the clinic is more than just a white building

When you visit a medical clinic in the United States, you direct yourself to a building in which various medical services are provided. In Afghanistan, the local medical clinic might be a physical structure devoted to healthcare, but within its walls very few services are likely provided. Your local “clinic” might even be the home of the government-appointed healthcare agent for your village. Your clinic might have a physician on duty, but most times you will only see there a poorly trained nurse or, even more likely, a local citizen with very minimal medical education who nonetheless is contracted by the Ministry of Public Health to provide the little healthcare he or she is able to offer the community.

I’m not implying the services always are poor, but they are certainly scarce. In fact, the Basic Package of Health Services for Afghans promoted by the Ministry of Public Health calls for little more than comprehensive vaccinations, pre- and post-natal care, treatment and control of malaria and tuberculosis, and nutritional supplementation. The ministry has not yet been able to provide for the entire population even this rudimentary package as resources – both human and financial – are lacking. The providers available often are not well-educated or trained, but they are committed. When you look at the scant stock of pharmaceuticals, vaccines and essential supplies available to these workers, you realize that even a US-trained physician would have trouble addressing the medical needs of the Afghan communities.

The construction of a proper clinic building is a source of great pride and hope for Afghan communities. It serves both practical and symbolic purposes. Practically, a clinic building serves as node where community medical treatment can be consolidated and then enhanced. In many remote places, providers dispense government-funded medical care in their personal residences as no dedicated local clinic structure exists. A clinic building also symbolizes that a community not only possesses cache and prestige, but that improved medical services might soon be available. The building itself therefore becomes a sign of hope, prosperity and advancement.

You must be cautious when constructing medical clinics (in addition to other government facilities such as schools and police stations) in Afghanistan as well-meaning donors and development personnel often have made the mistake of raising a building only to learn that the Afghan government lacks the resources to staff, equip and administer the facility. Then, your medical clinic becomes simply an empty white building with a red crescent painted on its wall.

How much is that pacemaker in the window?

Consider this scenario: You are a patient in an Afghan hospital, and your physician presents you with a prescription for an intravenous pharmaceutical he feels necessary for you to recover from your illness. He doesn’t write an order for the drug to be given by the nursing staff, because the hospital pharmacy doesn’t have the drug in stock. In fact, he probably doesn’t even give the prescription to you, as you are ill and bed-ridden. He probably gives the prescription to a relative of yours in the hospital with you who is there to attend to your needs such as food, laundry and bathing, as the hospital provides none of those services.

If the relative is able to afford the pharmaceutical, he or she proceeds to a local bazaar where a wide array of drugs can be bought with or without a prescription, even though the quality of the drugs is often suspect, especially those manufactured in Pakistan, China and India. (Afghanistan has made considerable advances in medical care the past several years, but the country is still far from developing a drug enforcement agency.) Medical devices are usually available at these markets as well.

The situation in Afghanistan is similar to that of many developing countries. The American surgeon Atul Gawande writes of the shortage of medical supplies in public Indian hospitals that has created such a demand for the goods that the hospitals are now surrounded by “rows of ramshackle stands with vendors selling everything from medications to pacemakers.” * In Kenya, I witnessed family members returning from local pharmacies with morphine, hypodermic needles and an assortment of IV fluids.

If you or your family cannot afford the required drug or device, you simply hope for the best. In these cases, the hospital wards merely serve as holding facilities or inhospitable hospice rooms.

Because Afghan physicians make very little money working in public hospitals, they do not always give their patients in those facilities proper attention. In fact, sometimes patients languish in those hospitals with no physician care whatsoever. Recently a colleague recounted for me how he found a surgical patient, recently transferred from another hospital with drainage tubes still protruding from his abdomen, wandering the halls of a Kabul hospital with his medications in hand, looking for someone to care for him. The patient claimed he had been in the hospital three days since his transfer, but had not yet spoken to anyone – physician, nurse or technician – on the medical staff.

Until some sort of plan for proper hospital services is drafted and funded, most of the Afghan medical centers will offer very little to the population. And until then, most hospitalized Afghans will, unfortunately, be wondering the same thing as much of the ambulatory patient population: “Is there any treatment available for me?”

*Atul Gawande, Better: A Surgeon’s Notes on Performance, p. 241.

Thursday, October 23, 2008

Critically Ill: Afghanistan's Healthcare System (Part Two)

This is the second article illustrating the challenges encountered in building a functioning Afghan healthcare system.

There is No System Here: The Example of Medical Waste Disposal

A few months ago my office began getting regular emails from American engineering teams scattered around Afghanistan who were alarmed that they were encountering medical waste improperly disposed in fields, ditches and trash dumps. The emails included photographs of used syringes and hypodermic needles, empty IV bags and soiled gauze sheets strewn on open ground. The engineers were shocked, and the subtext of their messages was “What are you medical folks going to do about this?” The answer, which for diplomatic purposes wasn’t included so bluntly in our replies, was “We aren’t going to do anything about it right now.”

Just as Afghanistan has no sound system for providing medical care, it has no infrastructure or service for disposing of medical waste. If you practice medicine in the United States, you take for granted that red plastic boxes designed for safe needle disposal are available in the clinic, and that when they are halfway filled they will be carted, along with larger red bags of other assorted medical waste, to a container where they will wait until the medical waste disposal truck comes to collect the garbage. Later, in places that I hope I never see, community-sized piles of medical will wait for incineration, with non-burning waste subsequently carted away for another type of disposal such as burial in land or disposal at sea.

The only concern I have with this system is the behavior of mob-infiltrated waste disposal companies that often cut corners, and thus increase profit, in their treatment of the waste, as evidenced on the New Jersey shoreline in the 80s when used needles, dumped from a trash freighter not yet far enough out to sea, washed ashore.

Afghanistan has no system yet to dispose of human waste, let alone medical waste. Kabul, the largest and most metropolitan of Afghan cities, has no public sewer system. The minority of the homes that have plumbing rely on trucks to empty their individual septic tanks, and the waste is then spread onto nearby fields, one of which is located just a few minutes drive from the center of the city. Outhouses are the most common lavatory in Kabul.

If an Afghan medical clinic has proper needle disposal containers and designated medical waste garbage bags, an unlikely proposition, then the personnel have no avenue to properly dispose of those receptacles once they are full. The Afghans have two choices: Let the waste sit in the clinic, or heave it onto the closest patch of barren earth or into the nearest open ditch.

At a few of the major Kabul clinics and hospitals, American development personnel have installed incinerators to ensure more hygienic medical waste disposal. The incinerators have solved some waste problems for hospitals, such as the question of how to dispose of flesh surgically removed from patients. Before, at a major Kabul medical center, amputated limbs and other choice bits of the human body that were not going home with the patients simply were buried on the hospital grounds. The only challenge was to inter the pieces deep enough so that local dogs couldn’t smell and unearth them.

But the incinerators brought new problems as well. Electricity often is unreliable in Kabul, and the incinerators don’t burn much without power. The incinerators are imported, rather exotic machines here. If one malfunctions, you cannot simply thumb through the Kabul Yellow Pages and pick the medical equipment repair specialist of your choice. The companies who sell the incinerators and other medical equipment typically have, at most, only a few service representatives for the entire country; and Afghanistan is about the size of Texas, with a transporation infrastructure that rivals that within countries such Mali and Papua New Guinea.

The hierarchical, bureacratic nature of Afghan medical facilities has also worked to subvert the use of what incinerators are in place. In one hospital, a specific employee is charged with collecting the building’s waste and the depositing it in a storage room. However, that employee does not possess the key to the storage room. The key to the storage room door is the possession of another hospital employee, who must coordinate with the waste collection agent to ensure that needle boxes and red garbage bags can pass through an open disposal room door to await incineration. The employee responsible for transporting the waste from the storage room to the incinerator, another actor in this tableau, also depends on the availability and good will of the waste disposal room keymaster so that the waste can transit from the hospital building to the incinerator itself. Thankfully, the door to the incinerator has no lock, so the transportation agent, if motivated, can deposit waste directly into the unit. However, the transportation agent has not trained to actually fire up the incinerator. The process of burning medical waste is the responsibility of another employee, qualified and facile in incinerator operation. Of course, the incinerator mechanic is helpless unless the machine has electrical power, which comes from a nearby outlet through an extension cord. The keeper of the extension cord is yet another hospital employee, hopefully collegial with the incinerator mechanic and willing to produce the cord so that the medical waste can burn.

Even if medical waste is burned properly in the incinerators, the Afghans have nowhere to dispose of the (hopefully sterilized) metal needles and ash. I don’t know where they deposit this stuff. My guess is that it somehow makes its way to field or ditch where American engineers, aghast at the sight of it, avidly photograph the scene and rush the images to us medical personnel. I contend that improperly disposed waste is an encouraging symbol as it represents the fact that Afghans somewhere were actually receiving some sort of medical care. I’m more concerned that most Afghan medical clinics still lack the supplies to even generate medical garbage.

Wednesday, October 15, 2008

Critically Ill: Afghanistan's Healthcare System (Part One)

Most medical professionals, when they first arrive in Afghanistan, are pretty shocked when they recognize the poor quality of medical care available in this country. The average Afghan probably has little to no access to healthcare at all, but what is available publically might be less than what an American can supply at home from the family medicine cabinet. Decades of war, corruption, destructive cultural biases and international indifference have devastated Afghan society, including the education system and national medical institutions. The healthcare system in Afghanistan today, where the government’s per capita expenditure is less than $3, is a dissheveled, ailing patient on its back and in need of resuscitation. I’m not able to dissect the entire system, examine its components, and then propose a plan to improve its functioning; but I can produce several vignettes which I hope illustrate the problems. Consider it a short primer, in two parts, on the state of Afghan healthcare today.

“Physician” is More a Title Than an Academic Degree

Until very recently, you didn’t have to do much to graduate from medical school in Afghanistan. Admission standards were extrememly lax, with several hundred students matriculating each year to the most prestigious medical school, Kabul Medical University (KMU). Once enrolled as a student at KMU, you didn’t have to attend class to graduate. Attention to the seven-year medical school curriculum was optional: No student failed, and students did not know the nuisance of medical competency and licensing exams. At the end of the seven year program, which essentially was a protracted lecture series, all students graduated with an M.D. degree and simply chose what field of medicine best suited them. Although some students entered residency programs at Afghan hospitals, such advanced training certainly was not required. You want to be a surgeon? Go ahead and cut. You’re a medical doctor.

Many US medical school mercifully utilize the pass-fail grading system, but students must then pass a series of national licensing exams before continuing on to further medical training and autonomous practice. The Afghan system was, unfortunately, pass-pass.

The system is slowly changing. Selection for a seat in a medical school class is now much more competitive, a fact that angers many influential Afghans who have grown accustomed to easily “enrolling” their kin in medical school. Tuition at the schools is free, so wealthy and connected Afghans often considered the academic excursion as nothing more than a seven-year shopping sojourn for their children. Additional rigor has evolved as at the end of the medical school curriculum as well, as graduating students must pass an exam in either medicine or surgery in order to practice.

These changes in medical education should produce more competent physicians in the years to come, but unfortunately the quality of physicians already practicing in Afghanstan varies tremendously. Many physicians possess an understanding of human biology not quite as extensive as that of a bright American high school student. Some physicians who have received advanced training in medicine or surgery nevertheless still lack a basic understanding of the fundamentals of medical intervention. An American orthopedic surgeon here recently considered it a victory that he persuaded the Afghan surgeons to stop sharing one set of operative instruments for the two surgical cases taking place in the same operating room.

Afghanistan does boast some very good and talented physicans and surgeons. Often these people have trained in the former Soviet Union, Pakistan or Turkey. Others are simply very dedicated, intelligent, and driven to provide the best possible care under the circumstances. Unfortunately, there are too few of these folks around, and it will be years before medical education reforms and training initiatives serve to stock the Afghan healthcare system with a preponderance of competent physicians.

If You Paid Me Like an Interpreter, I Would Practice as a Doctor

The monthly salary for a physician working at a public hospital for the Ministry of Public Health is about $50. Physicians working for the Afghan Army earn more, but still only $200-300 per month. An Afghan interpreter working in Afghanistan for the United States, another government, a foreign business, or one of the numerous non-governmental organizations (NGOs) here averages $600-800 as a monthly salary. Medical students in Afghanistan, as a population, have much better facility in English than most other groups of people. The quality medical texts available here are often written only in English, and the medical school curriculum (that is a seven-year program modeled on the British system) includes English language instruction. Therefore, a shocking number of medical school graduates in Afghanistan have no intention of using their degress to provide medical care to their countrymen. Instead, they graduate from medical school and immediately find employment as interpreters.

Many physicians who do work at the public and military hospitals are strictly morning employees. They cannot afford to support their families on their government salaries, so they practice at the government institution until about 13:00, then they depart to their private clinics where they attend to patients who are able to pay cash for their services. Some brazen physicians even utilize the government clinic buildings and equipment to conduct private clinics. Security at the military hospitals is often compromised as some physicians instruct their private patients to see them at the military installation, even though entry to those facilities is supposed to be restricted. At another government hospital, an advising American intensivist was shocked to find the Afghan ICU attending physician absent from the critical care ward every afternoon, but using internationally donated equipment and supplies on the ground floor of the hospital to conduct his profitable private practice.

The consequence of the pitiful salaries and short working hours of Afghan physicians charged to provide medical care to the overwhelming majority of Afghans is that the wealthy have the opportunity to pay for decent care, while the poor often have trouble even finding a physician they can afford to visit. The physicians themselves are stuck in a system that offers no financial security if you treat the needy. Moreover, many Afghan physicians who might look forward to a relatively lucrative private medical practice simply look to emigrate from Afghanistan. I know personally several well-trained doctors who chose to forfeit any opportunity to practice medicine as they secured visas and moved to the United States, where they will be lucky to live a middle-class existence after their arrival. No institution in the US will recognize their Afghan medical credentials, and they will more likely be driving a taxi cab than ever seeing clinic patients in any capacity. Their country misses them.

Sunday, September 21, 2008

COIN for the Realm: Novel Approaches to Counter-Insurgency Operations in Afghanistan (Part Two)

(This is the second article in a two-part seriesSee the previous post for part one.)

Operation Frigid Air

The warm weather months in Afghanistan long have been considered the prime fighting season. In winter, it’s just too cold to fight. Key roads and passes also become too difficult to travel with all the snow and ice. But I also believe that the considerable heat of the oppressive Afghan summer months brews irritability and anger in the breasts of many Afghans, who must leave their homes that have been transformed into literal mud-brick ovens by the summer sun. It is no coincidence to me that southern Afghanistan, the traditional home to the Pashtuns who comprise the majority of the Taliban, is also the hottest region of the country. Unable to stand the heat of their homes, many Pashtun men must loiter out-of-doors enveloped in a surly, violent funk, which makes them easy recruits for the Taliban who can promise immediate relief with a cooling, windy ride in the bed of a white Toyota pick-up truck. After a brief respite from the heat, the new recruits are more likely to take up with the Taliban and look for women to whip, books to burn, and children to chastise for such unGodly activities such as kite flying and marble shooting.

I theorize that an air conditioner in the home of every Afghan would keep most males inside during the summer fighting season, and render impotent the aforementioned Taliban recruiting strategy. At my base in Kabul, we make great use of the Chigo brand of air conditioner, manufactured in China and readily available in Afghanistan. Many Afghans have an aversion to Chinese goods, which the natives here think inferior even to Pakistani products. But I don’t think any Afghan would reject a free air conditioner, no matter what the brand.

The cost to install in every Afghan home a Chigo air conditioner would be substantial. At a unit price of $300 and an estimated five million homes to cool, Operation Frigid Air would generate a bill of $1.5 billion. Consider, though, that the US already has spent $172 billion in Afghanistan since 2001. At less than $2 billion, we could pacify a country for less than it costs to rescue a major US bank. Consistent, clean electricity for all the units would be problematic, but with potential Talibani indoors luxuriating in their pleasant 70⁰ F environs, the countryside and cities would be quiet. Development teams would then have the opportunity to build the utility infrastructure the country lacks, without the danger of insurgents destroying power lines and applying dynamite to hydroelectric projects.

Perpetual Star Strategy

One of the most popular television shows in Afghanistan is Afghan Star, a glorified talent show modeled on American Idol. The founder of Tolo TV, which produces Afghan Star, estimates that 11 million Afghans, or nearly one-third of the population, are avid viewers. You have to be a little suspicious of a viewing audience estimate from a television producer who surely will overestimate his production’s popularity, much like a D.C. protest march organizer’s participant estimate will usually quadruple the National Park Service’s figure. But I work with Afghans, and I will testify that they were all talking about the final episode of Afghan Star in March. One interpreter told me that it not only was his grandmother’s favorite television show, but the only program she watched.

The United States should assist in producing a continuous run of Afghan Star, perhaps even creating regional shows in the native languages that send their winners to a national competition. Afghans and Americans are alike in many ways, but especially similar in our avidity for televised camp. Entire villages gathered on common ground to watch the final episode of Afghan Star on the single small television available in their locale. The Afghans who did not watch the last season of Afghan Star likely missed the show only because they had no access to a television. Several thousand large-screen television sets distributed throughout the country and a perpetual dose of Afghan Star would leave the vast majority of the country too mesmerized by the national singing talent to ponder subversive activity. The interest in Afghan Star is so intense here that any noise or disturbance promulgated by the Taliban during an episode would draw swift vigilante justice by offended locals who would then scurry back to catch the remainder of the televised entertainment.

A Professional Approach to Finding Osama bin Laden

Although recent reports claim that he does not control the day-to-day operations of Al Qaeda any longer, and efforts to locate and capture him are not truly counter-insurgency operations, Osama bin Laden remains a fugitive that many Americans would like captured. Military experts and diplomats argue that the forbidding, tribally controlled terrain of northwest Pakistan, where bin Laden most likely hides, foils attempts to locate him. However, the difficulty in determining bin Laden’s whereabouts does not stem from the mountainous, rugged geography that engulfs him, but from the fact that the United States has not utilized available experts to pinpoint his whereabouts.

bin Laden’s full name, estimated wealth and last known location should be forwarded to an aggressive university development office with the additional misinformation that Osama is an alumnus known to distribute his wealth liberally to initiatives dear to him. If the Cornell University alumni donation experts were given the incentive to track down bin Laden, they would likely have a viable address for him in 2-3 weeks. I have attended three major universities, and I cannot shake free from any of them no matter how often I move. Sometimes I think that the schools each surreptitiously placed a LoJack beacon somewhere under my skin before I left the institution. The US military and our intelligence agencies are capable of amazing feats; but to find Osama, they should move over and let university development personnel, the true bloodhounds when it comes to this sort of work, take over the mission.

Friday, September 19, 2008

COIN for the Realm: Novel Approaches to Counter-Insurgency Operations in Afghanistan (Part One)

Photographs: I asked none of these Afghans to pose for snapshots.  I simply found them stationary and waiting for me to photograph them when they saw I had a camera.

In his latest book on the Bush administration, Bob Woodward attributes much of the reduction in violence in Iraq to a new military and intelligence strategy that has proven as revolutionary as it is effective. Somehow, and Woodward gives no details on exactly how, the United States has developed a widely successful approach to locating and eliminating insurgents in Iraq. Information on the actual techniques currently is classified information. I’m not sure if the military plans to incorporate similar operations in Afghanistan. I can offer, however, a few novel techniques that policy and strategy experts in D.C. might not have considered. These suggestions are in no way classified, but I believe them to be imminently applicable to the conflict in Afghanistan, so I encourage and welcome their incorporation into any other operations the United States military might be planning for securing peace in Afghanistan.

The Polaroid Lure

The strength of this technique is rooted in a simple cultural fact: Every Afghan loves to get his or her photograph taken. I think we have all encountered, both within the United States and elsewhere, people shy toward the camera. Especially in developing countries, many people are loathe to be part of any type of photodocumentation that might be perceived as evidence of their supposed backward, funny ways to curious foreigners. In Vietnam, I saw crippled, kyphotic elderly women stand and run when I raised my camera near them. In Cambodia, I witnessed a man fishing in a river with his bare hands who managed to duck under water and hold his breath for a period of time that would have impressed Houdini, thereby negating my opportunity for a snapshot. But in six months, I have not met a single Afghan unwilling to pose for a photograph.

At the Afghan National Military Hospital recently, I was walking the grounds photographing the new fountain and landscaping (all done at the expense of the ICU renovation) when I noticed that many people I was passing had stopped and posed, expecting me to photograph them. A few seemed quite irritated that I didn’t include them in shots of the nearby water and trees. You don’t need to ask explicitly for permission to photograph an Afghan. All you need to do is hold up your camera, and all activity in front of you will stop until you signal that you’ve taken all the photographs you need.

Military success in Afghanistan depends on the successful implementation of COIN: counter-insurgency strategy. The Polaroid Lure technique is a manifestation of COIN strategy in a most simple and elegant form. Let me reiterate the last sentence from the previous paragraph: All you need to do is hold up your camera, and all activity in front of you will stop until you signal that you’ve taken all the photographs you need. The Taliban are Afghans, mostly, and we’ve all seen pictures of them riding around Afghanistan in their white Toyota pickup trucks looking for women to whip, books to burn, and children to admonish for such unGodly activities such as kite flying and marble shooting. I theorize here that the joy you see in the faces of these Taliban is NOT simply a display of religious zeal and a devotion to a misguided revolution, but the reflexive exuberance of any Afghan to the placement of a functioning camera in front of him.

Most Afghans are even more than excited, in fact overwhelmed, if you are able to offer them a copy of their photographs. Such a gift creates an immediate and deep bond of friendship and gratitude. Personal photographs are treasured mementos here, and not simply because most Afghans cannot afford cameras. The gift of a photograph is considered a token of hospitality and appreciation, both extremely important values in Afghan culture; and especially in the culture of Pashtuns, who form the predominate ethnic group in Afghanistan and the majority of the Taliban.

The United States should issue every soldier, sailor, airman and Marine coming to Afghanistan a Polaroid One Step camera and several cases of film, with orders to provide an instant photograph for every Afghan met. Battle reports detail that, in combat, US forces typically encounter Taliban fighters at a distance of 700—1000 meters, close enough that the insurgents would be able to detect cameras in the hands of US military personnel. Let me reiterate the last sentence from the penultimate paragraph: All you need to do is hold up your camera, and all activity in front of you will stop until you signal that you’ve taken all the photographs you need. My theory holds that not only would the Taliban halt any military assault and graciously pose for a photograph, but after the benighted rascals received a personal snapshot of themselves, they would lose any urge to fight and consider us infidels quite good folk after all. The hearts and minds of the 99.99% of the Afghans who want nothing more than an end to conflict here also would be ours.

The cost of such an operation would be minimal, especially when contrasted with the cost of US military efforts in Afghanistan since 1991, a figure the Congressional Research Service estimates to be $172 billion as of July 2008. Even if the US military ordered at the list price of $75 from Amazon.com enough Polaroid One Step cameras for all NATO and US military personnel in Afghanistan, with an additional order of enough film for one snapshot each of the estimated 35 million Afghans (at approximately $1.50 per sheet of film), the total cost of operation Polaroid Lure would be under $57.5 million. The total cost would be even less with a bulk order from Polaroid if the federal government bucks tradition and decides that a contract price for goods bought in large quantities from manufacturers should be less than what the typical suburban consumer would pay when buying the item singly. Additionally, the bulk Polaroid purchase would finally provide solid evidence that military spending creates the vaunted economic spinoff that Congressional hawks like to tout as rationale for every tax dollar spent on expensive military procurement packages.

(Next blog post: COIN (Part Two, including Operations Summer Freeze and Afghan Star, and a strategy to find Osama bin Laden.)

Tuesday, September 16, 2008

Mazir-e-Sharif: A Trial with Wind, Dirt and a Troublesome Prostate

Whoever first pronounced that “forty is the new thirty” likely was not a male suddenly unable, at age forty-one if my case is exemplary, to sleep through the night without waking at least once to urinate. Typically this disrupted sleep is due to a prostate gland that, after four previous decades of relative dormancy, is now blossoming like a desert lily at daybreak; and which delights in tickling a bladder that subsequently demands evacuation no matter what the present volume. I certainly did not have this problem at age thirty. Now, in my early forties, I can rarely escape the nightly interruption, even if I attempt to dehydrate myself before getting supine for slumber. In fact, I could blood let myself to a near death before sleep but still find myself in the bathroom at 02:00.

I don’t mind the interruption if I am home, or even at my base in Kabul as the toilet is only several yards from my bed, and usually I can take care of business and be back asleep within a few minutes. But during my recent trip to Mazir-e-Sharif in northern Afghanistan, where I slept in quarters without bathroom facilities, I found the nightly physiologic intrusion more burdensome. There, on a US military base that simply is a collection of plywood shacks and large shipping container boxes sitting on packed gravel and fenced by stacked barricades, I awoke each night to the famed Afghan 100 Days of Wind – extended in Mazir-Sharif through the moonlit hours and accompanied by the ample airborne dirt and silt from the surrounding desert. Every night, I awoke and trekked in the dark thirty or so yards to the toilet trailer with my head down as the dirty air stung my eyes; but I did notice one night that young, thin trees planted by the camp’s headquarters, virtually stripped of leaves either by the wind or a local goat, bent at nearly ninety degree angles in the gusts.

Every night, before I even began another quest for uninterrupted sleep, I took notice of the wind. In fact, the first time I lay in my bunk I thought that an active loading dock sat behind my quarters, as I heard the intermittent percussion of wood and metal colliding. The following morning, I discovered that the sounds were from the corrugated sheet metal, used as roofing on the buildings and shelters surrounding me, lifting in the wind and then crashing together or into the wooden beams that were supposed to hold them firmly in place.

The dirt raised by the wind permeated everything, even the interior of the buildings themselves. The nearby Afghan military hospital, where I spent two days, had a film of dirt everywhere: on the floors, on the patient’s blankets, on the operating room equipment. The dirt simply overwhelms the new hospital’s air filtering system. I went to inspect the ophthalmology equipment at the facility and instruct the staff, which is devoid of an eye surgeon, on its use. The room marked “Eye Clinic” had been locked for months, and when we opened the door I felt as if I were Howard Carter as he peered through the hole he had drilled into sealed door of Tutankhamen’s tomb, for I saw everything inside the clinic perfectly preserved under a soft, quiet layer of silt.

The weather in Mazir-e-Sharif remains very warm, and I was grateful for the sultry climate in the middle of the night when I walked to the bathroom in shorts and a t-shirt. I also appreciated the air conditioners that cooled most of the buildings. The recirculated air may have been dirty, with thin clouds of dust visibly emanating from the air conditioners’ vents, but at least the buildings remained a pleasant temperature. I tried to focus on the comforting cool every night as I returned from the bathroom and climbed back into my sleeping bag, comfortable again below the waist but tasting on my tongue the ancient soil that permeates the air in Mazir-e-Sharif.

Tuesday, September 9, 2008


I lived in southern California for eight years and learned a few things about protecting myself during an earthquake. I know that you are supposed to take cover under a protective object if a quake begins, or better yet leave a building that is shaking in a temblor. Recent events lead me to conclude that the typical Afghan training for earthquake safety is a bit different, as a few days ago when I felt the floor beneath me suddenly begin to sway, the Afghan military officers who surrounded me made no movement to duck underneath the heavy table in front of us; nor did they break for the door. Instead, they looked at me with effusive smiles, and the officers who spoke English simply said “Earthquake!” with faces full of excitement and anticipation such that I haven’t seen since the last time I was on a rollercoaster with my young nephew Davey Boy.

The Afghan officers’ response was in keeping with the cultural notion of inshallah, which means God-willing and attests to the Muslim belief here that your individual fate is truly in the hands of God; and marks as foolish any personal attempts to evade the will of God. I’m not sure what the Almighty had planned for me during the earthquake, but I was pretty confident that as soon as the ground began rocking, I received a direct message from God instructing me to promptly get my ass out of the building. But a friendly Afghan colonel next to me put his hand on my shoulder to indicate that I should stay seated; so I was forced to subscribe to inshallah myself for a few minutes.

I had encountered the concept of inshallah before in another predominately Muslim country: Turkey. Just a few days before I arrived on a visit to an uncle working in the city of Izmir on a highway construction project, a Turkish laborer had fallen into a pool of water that unknowingly was charged with electricity due to a faultily wired pump working to drain the liquid. An American supervisor found the Turk not breathing and with a poor pulse, so he disconnected the pump, pulled the victim from the water and began administering CPR. To the amazement of all the Americans nearby, the Turk responded: He regained consciousness, and was pronounced healthy and fit after an extensive evaluation and short stay at a local hospital. The other Turks, however, were not impressed with the CPR performance or their countryman’s recovery. “Inshallah,” they claimed, indicating that God simply willed the recovery; and why was this American-construction-supervisor-turned-paramedic so proud of himself?

I never heard a comment from the Turk who survived due to the CPR. Apparently God instructed him to find employment elsewhere, as he never returned to the construction site.

The building that I felt rock during the quake here is a model of Eastern Bloc architecture and engineering, built in the 70s by the Soviet Union. Once the earthquake began, I remember thinking “This shack is coming down and fast!” but such a reactionary conclusion failed to acknowledge the sturdy Afghan construction found throughout the country. It’s not unusual to encounter remnants of a wall that would still be completely intact had not Genghis Khan’s mob assaulted it with the Mongolian equivalent of a Stinger missile sometime around the year 1250. Many buildings here are the products of masons who were absolute masters of their craft. Even the mud brick homes that look as if they will simply melt away in the near future are quite stout. The medical office building in which I withstood the earthquake had been upright more than thirty years, a testament to its structural integrity as it surely has withstood several earthquakes yet remains standing. In fact, the rule in Afghanistan is that, in the event of an earthquake, it’s much better to be in an older, tested building than a new structure that may not have had its girders rocked before.

The earthquake announced itself a bit differently from the few I have felt in southern California. I first noticed slow, smooth undulations of the earth. Then a brief pause interceded before the ground shook more violently for 10-15 seconds. After the initial action, I could swear I felt a series of delayed tremors, but then I realized that I was sitting in a rickety chair barely able to hold my girth; and what I thought were after-shocks were actually my own anxiety-induced spasmodic gyrations that had converted my contorting seat into nauseating carnival ride akin to the Spinning Teacup I rode as a kid whenever Drago Amusements came to the Kokomo Mall parking lot.

News reports gave the earthquake a 5.6 rating on the Richter scale, although it’s difficult to ascertain the magnitude of a quake in Afghanistan as the country has no agency to monitor the events. The epicenter was located approximately 100 miles northeast of Kabul, but thankfully no serious injuries or damage occurred. The earthquake reminded me that the geotectonic plates beneath me continue to move and ram each other, creating not only earthquakes but the grandeur of the nearby Hindu Kush mountains, the Korakoram range in Pakistan, and the remainder of the Himalayas beyond. I’m hoping the plates don’t engage in any more aggressive jostling for position during my remaining time here, inshallah.

Saturday, August 30, 2008

An Afghan Lunch

Interview for a job in the United States and there are several critical pieces of information you want to ascertain from your prospective employer, such as expected salary, retirement plans, and annual vacation time. Health insurance benefits will likely be forefront in your mind as well, and deserving of a query. In Afghanistan, a primary question for an employer is: Does this job provide a proper lunch?

Afghans traditionally take bread and tea for breakfast, followed by a large lunch and then a small supper. Most Afghans are poor, unfortunately, so what constitutes a large lunch varies by income; but also by job. Those Afghans blessed with employment, and especially those working for government ministries, the military, and large businesses, usually enjoy a lunch provided at the workplace; and that meal is, by far, the largest repast of the day for most Afghans. The lunch benefit is so important that an Afghan-American surgeon who has returned to his hometown of Kabul to start a medical clinic after more than 35 years of practice in Florida recently told me that he has problems recruiting qualified staff as his budget does not allow him to buy his employees lunch.

I’ve kept abreast of news reports detailing recent food shortages in Afghanistan and many other poor sectors of the planet; but if you sat down for the midday meal, as I have done, at a military medical clinic or an Afghan ministerial office, you would think you were living in the Fertile Crescent during a period of bumper crop harvests. The typical lunch I’ve seen (and eaten) begins when you receive a plate of rice voluminous enough to feed a small Chinese village. Often the rice will come as a traditional palao and include a combination of raisins, cherries, carrots and meat. The palao usually carries the aroma of cooking oil and butter indicating a quick light fry prior to presentation (a process that we all know makes everything taste better). Whatever the type of rice offered, your serving will be just short of a bushel.

If you stand up to peer over your serving of rice and scan the rest of the table, you will see several other standard Afghan dishes including a very tart yogurt that is slightly curdled and feared by many Americans as pasteurization has not yet made it across the Khyber Pass as standard practice in the dairy industry of Afghanistan. I like to use the yogurt, which is unflavored, as a condiment for my rice and meat because I like the rich tangy bite it provides. No Afghan has yet confronted me on anything improper about mixing dairy and flesh, perhaps because the Islamic dietary laws apply here, not the Jewish.

Stewed vegetables and perhaps lentils will also grace the table. Okra seems to be popular, especially a soft, moist okra that tastes slightly of cooking oil and butter, indicating a quick light fry prior to presentation (a process that we all know makes everything taste better). You might also have before you a thin soup with carrots and noodles.

Certainly you will have a plate of naan flat bread, and larger institutions have their own traditional naan ovens where bakers (often teenage boys working for a couple of daily meals and perhaps a bit of cash) knead and flatten the dough before sticking it to the underside of the ceiling of a wood-fired stone oven. At one clinic I visit regularly, my first stop upon arrival is at the house naan bakery for a piece of hot bread fresh from the oven. It’s my Afghan equivalent of entering a Krispy Kreme donut shop when the hot light is on. The edges of the naan are thicker and softer than the middle of the disc, which is thin and crisp. I’ve discussed with a couple of naan experts the possibility of baking full pizzas just as they bake the bread, as I thought that might be a unique and marketable Afghan twist on the already prevalent stone-oven pizza concept, but we cannot devise a method to keep the toppings from falling off the dough into the fire once the pie is inverted.

Naan at the lunch table is useful as a scoop for yogurt, a shovel for rice, and a pincer pad between your fingers for snagging meat morsels. Rural Afghans might not have any table utensils at all, and need the naan for manipulating the rest of their food. Most tables I’ve seen in Kabul feature silverware. Contemporary urban Afghans will even use their left hands to reach for naan if necessary, breaking a taboo against the cleanliness of the hand that traditionally performs necessary bodily hygiene maneuvers and therefore considered, for good reason, as unclean and not to be offered to guests in greeting or commingled with vittles.

The meat at lunch might be served in a small individual dish, cut into slender strips and mixed into the palao, or still attached to a large bone from the donor beast and sitting atop another tub of rice. I like the latter presentation best. I call it “Leg of Something,” as I’m never sure the species represented. I know what it is NOT: pork. But you can place your money on any other mammal, with goat the odds-on favorite.

The Afghans do not forget about dessert. You will see fresh oranges at lunch, along with lemons that many Afghans will slice and eat like any other citrus fruit. My favorite post-lunch treat is a peculiarly dry and slightly sweet melon, usually the size of an average watermelon, with white fruit and a yellow rind. I asked an Afghan colleague for the English name of the fruit, and he said, “We call it MELON.”

I asked if it is a certain type of melon, and he responded, “Like a watermelon, but just a MELON.”

My Dari is lackluster, at best, compared to his English. And I really don’t care what it’s called. It’s delicious, and I eat more than my share every time I find it on the table.

Friday, August 22, 2008

Taking Chai

Last week I attended a meeting with representatives from several Afghan health organizations committed to developing a medical plan to respond to disasters that hit the country. Considering the earthquakes, droughts, pest infestation, brutally cold winters and military devastation that regularly affect a sizeable portion of the population, a disaster response plan is imminently reasonable. So said an eloquent representative from one of the agencies, and he then began to expound on details and initiatives crucial to the nationwide coordination of a medical response. I was impressed, as I have found it rather unusual that an Afghan official actually takes control of a project and pushes his countrymen to produce policy and procedures beneficial to the population. Unfortunately, I wasn’t impressed for too long, as shortly after he began his disquisition, he stopped and said that he would like to say more about organizing a medical response program for the country, but as his tea (served to everyone several minutes prior) was getting cold, he must sit and drink it now.

I knew that the taking of chai, as tea is known here, is an important custom at meetings in Afghanistan. I was unaware, however, that a warm cup of the beverage took precedence over the promotion of improved public health for the country.

Upon entering an office or residence or meeting in Afghanistan, you invariably will be offered a cup of chai. The tradition is testament to the Afghan custom of hospitality. Along with the chai, you usually receive a small piece of candy or a dish of nuts. The taking of chai is common and important in many Middle Eastern and Asian cultures, and oftentimes true business cannot be comfortably discussed until initial greetings and chai are complete. Chai is so much a part of the culture that an office or ministry in Afghanistan typically has one person appointed to serve the drink at meetings.

I first encountered the concept of the “chai boy” in Turkey, when I visited an uncle who is a civil engineer and was managing the construction of a freeway around the city of Izmir. I went to the worksite with him one day and sat for a meeting between him and a few Turkish contractors. Shortly after discussions began in the double-wide trailer that served as his office, a Turkish man who looked thirty-five years old entered carrying a tray laden with one cup of chai for every man in the room. I watched as this same man waited for us to finish our chai, after which he retrieved the cups and disappeared.

After the meeting, I asked my uncle why that employee didn’t stay for the discussion. My uncle, confused, asked which man I referred to. “The one who brought in the tea,” I answered.

“You mean the chai boy?” my uncle responded.

Not familiar with the term or occupation, and not yet ready to believe that a thirty-five year old man could actually support himself serving tea to engineers at a construction site, I responded, “Yeah, I guess. Your employee who brought in the tea. What’s his position here?”

My uncle looked at me as if I had just questioned the precepts of Euclidian geometry. “Ron,” he said, “That guy is the chai boy. That’s his job. To serve chai.”

At the meeting last week, a Ministry of Health chai woman charged us with chai and candy shortly after proceedings began; and when the gentlemen who suddenly found himself unable to continue with the important task of creating public health policy for Afghanistan due to a cup of rapidly cooling chai, a quick-thinking fellow Naval officer summoned the woman, somehow gesticulated the request for a fresh, hot cup of chai to the table post-haste, and then quickly served the chai to the health official who, obviously bolstered by the steaming brew now below him, took a quick sip of the just-delivered beverage and then continued on with a rather impressive proposal for mitigating the medical plight of Afghan victims of national disasters.

Another recent incident illustrates as well the propensity for Afghans sometimes to value their chai above important matters at hand. Last month I went with an American pediatrician to examine and vaccinate at his home the infant son of a very high-ranking Afghan politician. My colleague and I completed the exam, and then began to examine closely the infant’s medical record as past vaccinations were not well-documented. We hadn’t seen the record before we arrived at the politician’s home as the child’s mother maintained the chart, and we weren’t sure we would see the child again during our tenure in Afghanistan; so we wanted to review and update the record properly.

The politician’s housestaff included a young man who had recently graduated from Kabul Medical University, who told me that he hoped to matriculate to Canada soon to begin a residency in neurosurgery. He was a relative of the boy, clearly affectionate with the child, and grateful for our examination. A few minutes after we began reviewing the medical record, however, he began to shift uncomfortably in his seat. I noticed that the child’s mother had left the room, and I assumed that she had moved to the kitchen to prepare the inevitable chai. Apparently the budding neurosurgeon knew himself that chai now awaited us, as he allowed us only two or three more minutes with the record before he became so agitated that he quite literally jumped to his feet and exclaimed “Please, we must finish here! It is now time for chai.”

Canada is part of the British Commonwealth, a collection of people who, like the Afghans, take their tea pretty seriously. Still, I think that a Canadian neurosurgeon, given the choice between a taking tea break or properly documenting a patient examination, would probably choose to complete the medical record according to established standards. I’m not sure if that young Afghan physician will ever undertake surgical training in North America, but if he does he will quickly learn that if he wants chai during the workday, he’s going to have to wrap the beverage cup in a cardboard sleeve and enjoy his drink on the go.

Saturday, August 16, 2008

Sitting for a Kuchi Tribal Council

The Kuchi peoples are the last of the nomads in Afghanistan. They migrate with the season, maintaining a lifestyle that befuddles most other Afghans. The outskirts of Kabul host several different Kuchi settlements, usually clusters of hundreds of low-slung black tents. One of my interpreters shook his head and gave me an incredulous look when I asked him about the Kuchis. “Many of them have money. They own businesses,” he said. “But they like living in those tents.”

I recently visited a Kuchi camp east of Kabul. I was expecting to see a mobile canvas metropolis, but instead found myself in the middle of a small mud-walled village with a single, narrow street that barely accommodated my five-vehicle convoy and the five hundred Kuchi men and boys who appeared to be waiting for our arrival. 250 of these males began to direct us to various parking spaces, none of them large or secure enough for our vehicles. The other 250 were intermittently assaulting an international aid truck distributing large bags of grain (clearly another factor that drew the crowd). I was driving one of the SUVs in the convoy, and after idling among the throng of Kuchis for a few minutes – each one of them gesticulating for me to proceed in a direction different from what his neighbor urged – a few Afghan policemen with AK-47s and nasty looking sticks that resembled horse-whips literally beat people away from my vehicle, and directed me to back into a gate that opened along the walled street.

I was traveling with several other military medical colleagues and a delegation from the Afghanistan Ministry of Public Health led by the Deputy Minister. The ministry, at the urging of the Kuchis, wants to build a medical clinic at the settlement. Before we departed Kabul, I questioned why anyone would seriously consider constructing a permanent medical clinic for a group of nomads. The answer came back that Kuchis collect at this particular spot outside Kabul every year, and in fact many of the tribe intend to settle there permanently.

The president of Afghanistan, Hamid Karzai, has been trying to stop the Kuchi migrations across the central and southern regions of the country. The Kuchis are ethnically Pashtun, the same as Karzai, so he may wield some influence in convincing the Kuchis to abandon their nomadic heritage. He certainly could do without the recent political controversies involving the Kuchis and their alleged squatting on lands claimed by other ethnic groups. Over the past few months the Kuchis have been battling – both verbally and physically – the Hazara, who live and raise livestock in a couple of provinces near Kabul. Both groups lay claim to grazing lands made scarce this year by low amounts of rainfall, and both groups claim murder of their kin by the other.

The Hazara for centuries have been the abused minority of Afghanistan. They are Shiite Muslims surrounded by devout Sunnis. Moreover, they are descendents of Genghis Khan, and thus a reminder of that invader and his rampaging horde who rose from Mongolia to sweep through Asia. In what is present-day Afghanistan, the Mongols simply destroyed most of what they encountered, deposited a considerable amount of their DNA, and left a rudimentary governing military structure. But most of the Mongols left the Afghan lands shortly after they ravaged it, and rode on looking for the thrill of pillage elsewhere in Central Asia. Ironically, the Kuchis, who now are rivals of the Hazara and more than willing to use their Pasthun ethnicity (which in Afghanistan makes for considerable political muscle) to encroach upon Hazara land, may never have come to prominence at all in Afghanistan had not Genghis Khan slaughtered the sedentary tribes of the country while the mobile nomads hid in the hills and caves, waited out the invasion, and emerged later relatively unscathed. Quite suddenly, the nomads found themselves a prominent political force due to the shockingly high attrition rate for anyone standing stationary on flat land as the Mongol horseman rode by.

The entirely male Kuchi delegation that awaited us at the settlement included the group’s representative in the Afghan parliament, its mullah, and 25-30 other elders and clan leaders from the local settlement. We met in a long, narrow room one floor above the bustling street. At the head of the room sat the mullah and the Parliamentarian, flanked on both sides by the Deputy Minister, a few of his staff, and us Americans. None of the Kuchis seemed bothered that we Americans were wearing body armor and helmets, and carrying loaded M-16 rifles that we simply leaned against a wall or placed in front of our feet on the carpeted floor.

We had also left two men from our convoy at the vehicles to guard them. That is standard military procedure when parked in an insecure location. In fact, our initial reaction when we drove into the main square of the village to find ourselves surrounded by hundreds of Kuchi males in loose-fitting, traditional Afghan dress who were unable to resist the urge to nuzzle our vehicles was: This is the scenario that our combat survival instructors in the US told us to avoid at all costs. After learning that we were to meet with all the leaders of the community, however, we realized that in fact we were probably safer in that village than we would be anywhere else in Afghanistan. The governing patriarchy was welcoming and surrounding us, and the Pashtun tribal code calls for unbridled hospitality to one’s guests. Additionally, we were there to present a gift: a new medical clinic. Certainly the word was passed long before we arrived that the Americans are to be welcomed and escorted safely to and from the village.

The minister explained in English that before we talked of the medical clinic, we would "of course follow the cultural customs," and that was when the blind muezzin across from me began chanting select verses of the Koran that nobody but the mullah seemed to understand as the performance was sung in Arabic. Following the religious formalities, a few of the Kuchi rose individually to make statements that not even a fellow Naval officer who is Afghan-American understood, as the Kuchis were speaking Pashtu and not the officer’s native Dari. So we simply waited out these monologues and the spirited ten-minute conversation between the minister and the Kuchis that followed; and at a point when the dialogue seemed to ebb a bit, the ministry representative sitting next to me leaned into my ear and said, “Oh, sir. They want us to build a 200-bed hospital here!” a project much larger than our plan for a medical clinic plus twenty-bed inpatient ward. Another five minutes of spirited Pashtu ensued, and my neighbor leaned over again and whispered “They say they have more than 100,000 people here now!” And after a few more minutes of Pashtu interlocution, even the minister who was leading the discussion looked nonplussed as he stopped the Afghan-to-Afghan dialogue and exclaimed in English to us, “They say they have not 100,000 people here, but more than 100,000 families!”

The typical Afghan family has around eight children, and the Kuchis themselves may be procreating at an even greater rate as one elder rose later in the meeting, came to the front of the room, and claimed (as I learned through the Afghan next to me) that he has two wives and twenty-six children and that the settlement needed a full-scale hospital to serve the burgeoning population. It took a several seconds for the native English speakers to get the translation that this man had fathered twenty-six offspring, and the Afghans present just looked at us with lascivious grins until a couple of Americans started clapping their hands in appreciation for this contemporary Abraham; and then everyone in the room starting cheering and laughing as that most fertile gentleman walked proudly back to his spot on the carpet. That individual Kuchi’s productivity notwithstanding, I found myself in disbelief that upwards of one million Kuchis had located themselves in that settlement. The entire population of Afghanistan is thought to be 30-35 million, and I doubted 1/30 of the entire population sat bivouacked outside the village walls.

Of course, the supposed settlement population was merely specious bargaining data for the Kuchis gathered around us. They wanted the biggest and best clinic they could get, and at one point their Parliamentarian and the mullah were literally leaning into the minister and demanding that he promise them today, in front of their fellow tribesmen, that he would build a 200-bed hospital for the settlement. The other Kuchis seemed well-schooled on the coercive power of an intimidating majority, as they stood (sometimes two or three simultaneously) and offered mandates of their own to supplement their leaders’ injunctions as the latter literally collared the minister, who at this point was perspiring noticeably.

I make no presumption to understand the intricacies and nuance of Afghan culture and interpersonal communication. In fact, the more time I spend here, the less often I am apt to even speculate on what is actually taking place before me as Afghans speak and smile and gesticulate among themselves. So I was only a bit shocked when, three minutes after the Kuchis seemed intent on strong-arming for themselves the Afghan equivalent of Beth Israel Hospital, the minister, looking somewhat less moist, turned to the us Americans with a triumphant grin and announced, “So, it is now concluded. We will build the original plan for the clinic and the twenty beds. Perhaps with the ability to expand later.”

Everyone seemed extremely pleased, and as I looked around the room every Kuchi had a smile on his face. Apparently no more words were needed, as cans of cold soda pop were distributed to everyone in the room and we all shut up so we could drink. I watched the muezzin quickly drain one can of Pepsi, and then a second, after his neighbor kindly opened the cans and gently placed them in the blind man’s hand.

Below is a short slide show with more photographs from the event.