Thursday, May 29, 2008

How NOT to improve the plight of the typical Afghan

Yesterday I was returning from a project in a village just outside Kabul when our convoy of Humvees came to a stream that bisected the road. It’s not unusual when traveling the roads around Kabul for the path to truncate at a ridge or field or waterway where a causeway has yet to be built. The water at this particular obstacle was still and lie at the bottom of a channel that was no match for my Humvee or its driver: she simply slipped the machine into low gear and plowed through the muck and liquid. We sank tire-deep into the soft bed of the stream as we drove through it, and when water splashed over the Humvee our cab filled with the smell of sewage. The innards of our vehicle stayed dry, thankfully.

The village next to that sewage stream lacks much more than proper plumbing. Not immediately next to the sewage flow, but still far too close to it, children pumped water from a manual well. None of the streets of the village are paved and tremendous clouds of dust and dirt trailed our Humvees. Most of the homes and buildings are constructed of mud bricks. The needs of that village are exemplary of the needs of most Afghans, and the needs are basic: clean water, proper sanitation, decent housing and all the other public health measures and protections that the United States developed in the 19th and 20th centuries.

Occasionally my office will get proposals from organizations that don’t seem to recognize that simple projects -- not high-tech, complicated initiatives -- are the endeavors appropriate for assisting most Afghanistan. Although I’m sure these people mean well, their proposals are often laughable as they clearly have no understanding of the lack of physical infrastructure and socioeconomic support here that would conspire together to ensure their projects failed.

The latest proposal I read this week (shortly after driving through the river of raw sewage) called for an initiative to create an electronics laboratory in Kabul that would enable Afghans, especially those injured and maimed from mines and other weapons, to develop electronic devices, software and computer-controlled machines. The organization proposing this lab has a greater mission: to bridge the “digital divide” in poor communities and to improve the “technoliteracy” of populations deprived of the latest advances in technology. I see more than a few problems with the proposal.

The lack of technoliteracy is certainly an issue in Afghanistan, but the lack of basic literacy is a much greater problem. I think I knew how to read and write my native tongue before, in junior high school, I tackled the Basic programming language of the Radio Shack Tandy computer, and then moved on to master the remarkable Commodore 64. Perhaps we need to ensure a quality primary education for Afghan children, including the girls, before we worry about producing a generation of software designers here. I can also guarantee that initiatives to further train Afghans in skills that presuppose literacy and a rudimentary education will only further separate the privileged from the poor, disadvantaged and neglected. Afghan society is supremely hierarchical, with a few wealthy and educated folks controlling most of the economic resources, social power and educational opportunities. Development and assistance efforts need not completely ignore that segment of the population, as it is highly influential and typically a social conduit for foreigners to all else Afghan; but initiatives need to be structured so that the needy, which comprise about 99.9% of the population, are served.

The “digital divide” is another stark contrast between the have and have-nots in our world, and the chasm that surrounds the typical Afghan is quite shocking to most of us accustomed to computers and software and all the other elements of the digital revolution that keep us pecking at our keyboards instead of conversing with our friends and families. But the village kids who run alongside our vehicles with one hand outstretched and the other gesturing toward their mouths are not pleading for a laptop computer: They are asking for bottles of clean water that they know we keep in our vehicles at all times. I don’t presume to speak for the population here, but I think a priority for most Afghans would be for us to assist them in bridging the clean water divide before we address the digital divide.

After pondering the digital divide, I quickly drafted a list of other divides that I think trump the shortfall of digital technology in Afghanistan. I ranked the divides according to priority after I compiled them:

Top Afghan Divides
1. Nutrition Divide
2. Clean Water Divide
3. Literacy Divide
4. Sanitation Divide
5. Healthcare Divide
6. Viable Shelter Divide
7. Human Right Divide
8. Hygiene Divide
9. Living Wage Divide
10. Modern Utility Divide

94. Applied Technology Divide
110. Digital Divide
125. Wireless Internet Access Divide
133. Bluetooth Divide

Another quick thought on the specter of the digital divide in Afghanistan: Efforts to advance digital technology likely presuppose a constant supply of reliable electricity. I propose a drastic improvement in the power plant capabilities of this country before we worry about installing wireless internet service. If I were a politician, I would promise a reliable light bulb in every home.

Finally, I think any development initiative that provides electronic skills to Afghans must consider that more than a few insurgents in this country are eager to acquire the knowledge necessary to create sophisticated explosive devices that typically kill and injure Afghans, not foreigners, when detonated. Today a suicide bomber in Kabul drove his vehicle of charges into an armored American military SUV. The Americans in the vehicle survived with minor injuries, but four Afghans on the street near the explosion died and three others were injured. The Associated Press reported that children’s’ shoes were seen strewn about the site. Most Afghans want peace and a secure livelihood, but a laboratory serving a segment of the population interested in learning about homemade electronics runs the risk of educating the local equivalent of the guy who enrolled in flight school with no interest in lifting or landing an airplane, only controlling it once in flight; and he used that training to fly a jet into the World Trade Center.

Monday, May 19, 2008

Biblical plague strikes northwest Afghanistan

I’m not a Biblical scholar or an historian of antiquity, but I find it pretty easy to imagine a string of natural disasters that overtook the Egyptians thousands of years ago and which, over time, became such powerful collective memories for the Jewish people that the recollections became Myth and eventually documented in the Book of Exodus as evidence of the variety of products available to Yahweh when He went looking for a can of whoop-ass to open up on populations gone astray.

The peoples of northwest Afghanistan are mostly ethnic Persians and Turks and not descendents of the ancient Egyptians, but lately they must be feeling that a pharaoh of their ilk somewhere has done something terrible to raise the ire of God as they are withstanding yet another plague of Biblical fame and severity: locusts. This insect infestation is nature’s latest sucker punch into the gut of a region that just endured a brutally cold winter and continues to suffer from drought. Afghan health officials also fear that much of the wheat in one of the poorest provinces, Gulran, may be contaminated with the toxic weed charmac whose seeds get mixed with the grain and induce a toxic liver syndrome especially deadly to people already chronically malnourished (a group quite prevalent in northwest Afghanistan.)

The swarms of locusts, which can number in the millions or even billions, can quickly devastate and denude thousands of acres of crops. Afghan authorities describe the current swarm as “unprecedented,” and are offering 15 lbs of wheat for every kilogram of dead locusts. So far, Afghans have killed more than 300 metric tons of the insects.

Locusts are usually solitary creatures and researchers have long wondered what provokes the insects to suddenly swarm together. I was also curious why recent accounts of large locust swarms arose from regions chronically devoid of much arable land and growing grain (e.g. northwest Afghanistan and northeast Kenya). If I were a locust and looking to group with a billion of my own kind for a feeding frenzy, I would swarm where the land is rich in crops. Observant scientists have proposed some explanations that revolve around topics also relevant to the Old Testament: sexual arousal and fratricide.

Academics at Oxford propose that locusts have sensitive hairs on their legs that when stroked stimulate gregarious behavior. I’m not kidding when I write that the scientists call these hairs the locust G-spot. No scientific publication has yet confirmed enhanced locust orgasm with G-spot stimulation or that a locust swarm is simply a hovering, mobile insect orgy. The main activity of the swarm, I thought, was eating; and the Oxford group did not theorize if increased locust libido underwent sublimation into ravenous hunger. A human example of that, I suppose, would be a dinner party where all the guests engaged in such a fervid bout of under-the-table calf-rubbing and thigh-massaging that, instead of peeling off in pairs to copulate, they all got up and as a group rushed to devour sequentially the contents of every other neighborhood kitchen.

University of Sydney scientists posit a theory somewhat akin to the Cain and Able story that also explains why the locusts often swarm in barren lands. These researchers contend that the insects begin swarming after vicious abdominal biting due to the lack of other suitable sustenance. The locusts aren’t necessarily jealous of one another, just damn hungry. Hungry enough to turn cannibalistic. Then a vicious cycle begins where each individual locust simultaneously flees from another predator locust while pursuing more same-species prey, and the swarm is on. These scientists found that a locust can live and fly swarm with most of its abdomen eviscerated, an impressive finding but information I find confusing as it seems that the evisceration would be the equivalent of locust gastric bypass surgery and reduce the appetite so much that the insect would simply drop from the pack to find solitude once again – and pray that dumping syndrome doesn’t set in.

Sunday, May 11, 2008

Afghanistan's tallest man knows nothing about basketball

Photograph: It’s not a cut-out figure. It’s Afghanistan’s tallest man standing next to me.

From a distance I saw him entering the hospital and the other Afghans, whose average height approximates that of Americans, looking at him in amazement. Two physicians who had taken photographs of him with their cell phones looked at me, recognized that I, too, was shocked by the man’s height, and said “The tallest man in Afghanistan!”

I did what any reasonable person would do: I rushed into the hospital to get a photograph with him. I found him just off the main lobby waiting for the elevator; and when I asked Abdul Mutalib by voice and gesticulation if he would pose with me for a photograph, he smiled and said yes. (I know very little about the Afghans as a people, but I am sure of this: They will abort any activity to be subject of a photograph, no matter what their height.) While Abdul’s companion took photographs with my camera, two dozen other Afghans gathered in front of us to marvel at Abdul’s height and take snap shots of us with their cell phones cameras.

Although Abdul speaks very limited English, I asked him the question that I’m sure was forefront in the minds of everyone gathered there: Do you play basketball? He looked puzzled by my inquiry, but even more confused when I pantomimed a jump shot. (Two young boys present both giggled, clearly unimpressed with my limited vertical leap.) Abdul did understand my Dari when I asked him his name, and he then told me, in broken English, that he was at the hospital for his feet which give him all kinds of problems. He then ducked into the elevator, which has a ceiling height of about six feet -- which was at least 1 ½ feet too low for Abdul. (I should have photographed Abdul as he folded himself into the elevator car, but I was distracted again by the two young boys who now where not only giggling at me, but pantomiming jump shots themselves. I must say, their form showed promise.)

Abdul impressed me immediately for two reasons. First, although he was extraordinarily tall, he had a symmetric physique. Some “giants” suffer from acromegaly, which is a disease of increased growth hormone and usually leaves the hands and facial bones disproportionately large. Think of the motivational speaker Anthony Robbins. Other extremely tall people sometimes have a condition called Marfan Syndrome that produces abnormally long, thin limbs. Speculation holds that Abraham Lincoln was a victim; and some people believe that Osama bin Laden has Marfan Syndrome. (I’ll not be journeying to the Afghan-Pakistan border on a medical mission to confirm that diagnosis.)

The second observation of Abdul that impressed me tremendously was the fit of his suit. Even though he towered more than seven feet tall, he was a rare Afghan picture of sartorial splendor. I haven’t noticed any Big & Tall shops in Afghanistan, but even those odd-sized specialists wouldn’t have anything in stock for Abdul. I’m upset that I didn’t get the name of Abdul’s tailor, as a nice suit of clothing for my 5’ 10’’ frame would be a simple project for a man able to convert an acre of wool gabardine into an impeccable outfit for a seven-footer.

An Afghan interpreter, after seeing the photograph above, recalled a television interview of Abdul. He is a farmer from southern Afghanistan. I would like to see Abdul’s tools, as he surely possesses the world’s longest garden hoe and spade shovel. The television show also proclaimed him the world’s second-tallest man. I’m not sure where the world’s tallest man resides, but I recommend he come to Afghanistan and visit Abdul’s tailor when he needs a new suit.

Saturday, May 10, 2008

The dead get priority

The American colonel did not think he was proposing anything radical when he explained the priority with which battlefield casualties are evacuated by helicopter to medical facilities for treatment. “Triage efforts,” he said, “determine the most serious casualties and those are designated for airlift out for treatment.” I’m sure his category of “serious casualty” meant a soldier who was wounded but still alive (although a dead soldier would assume the status of worst casualty imaginable.) The Afghan Army general present simply smiled, and then said something that stunned every American in the room. “Yes,” he said, “the wounded are important. But the dead, they are more important.”

Certainly, he continued, the bodies of the dead would receive priority for helicopter transportation to the nearest available facility so that they could be prepared for burial. Only then would resources be directed toward evacuating the wounded. A corollary to his argument, I suppose, would be that any wounded soldier who died while waiting for the corpses around him to be cleared from the triage area would assume a more urgent evacuation status upon expiring. The irony is that death, not injury, assures these soldiers the most rapid transport to available medical care.

The rational for the priority of the dead over the injured is the Islamic injunction that Muslims must be interred within 24 hours of death. I’m not sure of the spiritual consequences to the dead or responsible burial party should a corpse sit above ground for longer than a day, but the Afghans are taking no chances with their war dead. In fact, care for the dead is a such a priority that the hospitals allocate an inordinate amount of money and personnel, from the perspective of most Americans working here, to mortuary and burial affairs considering that the facilities are chronically short of basic supplies and equipment necessary for maintaining patients’ lives. Last week I attempted to procure from the head of a local hospital reliable data on the number of patients seen in the hospital and its local clinic. I also inquired about the hospital’s mortality rate. The physician had unreliable data for every category except the number of deaths last year in the hospital. “I know this number is correct” he told me. “I know it is correct as I provided every death with a casket. It’s a large item in my budget.”

Afghan priorities do not always mirror the priorities of the American medical personnel sent here to work with them. At the aforementioned hospital a huge reflecting pool (see photo to right) in front of the building has been refurbished, and it pains me to even speculate on the cost of that beautification project. Hospital authorities apparently insisted that the grounds of the complex be restored to their former state, and the restoration included planting beautiful roses, installing planters with flowers, and repairing the reflective pool. (The pool will certainly be the cleanest and most sanitary area of the hospital.) I applaud the landscaping, but I think I would have looked to improve the ICU or emergency department before I groomed the hospital lawn. Or I might have installed a proper, functioning medical waste incinerator as currently amputated limbs and all other discarded human tissue are simply buried in a remote corner of the hospital grounds. I'm not sure if Islamic law dictates that even extracted gall bladders and severed appendages deserve a quick burial. An Afghan at the hospital told me that human tissue is buried to keep it from the dogs.

But this isn’t my country, and it’s not my hospital. And the oftentimes befuddling projects and priorities I encounter here are not always disconcerting. Behold, as an example, the “jingle truck.” The so-called jingle-truck is a standard dump truck or heavy-duty hauling vehicle that nevertheless has an elaborate, beautiful paint job and ornate metal chains that hang from its carriage and chime as the truck moves. The truck in the photo was making a delivery on base right outside the door of my quarters. The driver, like every other Afghan I’ve met, was delighted to pose with his truck for a photograph; and he even insisted on “playing” the chime chains by stroking them with a plastic water bottle. On a recent trip through an industrial section of Kabul, I saw a line of at least two dozen jingle trucks apparently waiting to be hired. If I were looking to hire one of them for a job, I would have selected the most ornate jingle truck available.

Tuesday, May 6, 2008

Politically nuanced quote of the week

I was away from Afghanistan for the Taliban.

-from the curriculum vitae of Brig. General Zahoor, Afghan National Army medical officer, to justify a gap from 1996-2002 in his professional chronology.

Sunday, May 4, 2008

When your only food may kill you

Please add contaminated grain as another tangible threat to innocent Afghans. Toxic wheat joins a list that already includes malnutrition, tuberculosis, malaria, civil warfare, female enslavement, Islamic extremism, dire poverty and drought.

In the northwest corner of Afghanistan, bordering Iran and Turkmenistan, sits the district of Gulran, where in 1974 an epidemic of liver disease struck the poorest families in several district villages. More than 20% of these villagers displayed clinical signs of liver toxicity, and the Afghan authorities determined the etiology as bread whose wheat was contaminated with the seeds of the charmac plant (Heliotropium). Charmac is a weed inadvertently harvested with the wheat, and the seeds contain pyrrolizidine alkaloids that inflict severe liver injury. The toxicity leads to a progressive, massive abdominal distention from fluid accumulation in the gut (ascites) as the liver degenerates over several months in a process somewhat similar to accelerated alcoholic cirrhosis.

Some villages in Gulran are suffering another epidemic of liver toxicity. New, dramatic cases of ascites began in November, 2007, again among some of Gulran’s most impoverished families. Many if not all of the victims are chronically malnourished and subsist on a diet of wheat bread that is occasionally supplemented with meat. (Very few fruits or vegetables grow in Gulran.) The cruel irony is that the little food these villagers have available might be killing them.

Health authorities transported several patients with severe disease to Indira Ghandi Hospital in Kabul for treatment. I visited these patients yesterday, and the first I saw were a pair of young siblings whose parents had both died recently from the disease. The next patient was a twelve year-old girl in such an advanced stage of illness that I would be surprised if she is still alive. She had a gaunt, weathered face that was absolutely skeletal, and I thought of the terrible newsreel footage depicting concentration camp victims liberated at the end of World War II. She looked ghastly. Thankfully, blankets covered her massive belly. Her limbs were so emaciated that the skin outlined the contour of her bones.

Initially I wanted to take a photograph of her, but I changed my mind quickly as I thought the attempt would be crass and vulgarly voyeuristic. Instead, I recalled another twelve year-old girl in Kenya whom I watched literally drown to death in a hospital bed over the course of a week due to congestive heart failure. Rheumatic heart disease had shredded her cardiac valves, and the damage had reduced her heart’s pumping capacity so much that blood collected in her lungs and saturated the pulmonary tissue, and eventually the mitigated oxygen exchange couldn’t sustain her. $5 worth of penicillin earlier in her life when she had a case of strep throat might prevented the cardiac disease. At least the Afghan girl had a bed of her own, as the Kenyan patients slept two-to-a-single-bed laying opposite directions on the mattress. If the Kenyan staff expected you to die within the next few hours, they would move your bedmate and place a screen around you, an effort that gave a bit of privacy in a crowded open ward and left the other patients less unnerved.

I haven’t cried over a sick patient since medical school, but I felt my eyes moisten when I saw that dying Afghan girl and the new orphans across the ward from her. The worst of the world’s cruelty seems reserved for the poor, young and defenseless. These children come from an agriculturally barren district, likely have a genetic predisposition for liver failure and suffered malnutrition before they even ate the contaminated wheat. Two of them were treated for tuberculosis the previous year. They are getting delayed but appropriate supportive care now in the Kabul, but they are so sick that they may die alone in the hospital away from any family members who have survived this latest epidemic. Mickey Mantle inexplicably popped to the top of the liver transplant list after years of pickling himself with booze, then he died only a few weeks later and took that precious donated organ into the ground with him. These kids have no prospects for such advanced medical treatment.

The two children in the photographs above are medically stable and the physicians think they might survive the liver toxicity. They still have dramatic abdominal swelling due to ascites. The boy seemed obtunded when we spoke with him. The girl was stationary but playful (look closely at the photograph and you can see that she is all belly under her dress), although at first afraid of a toy we gave her. In fact, all of the children were initially frightened by the stuffed animals we offered them, and one of the physicians told me they probably had never seen such a toy before.

Thursday, May 1, 2008

Fast Friends and Close Colleagues: The Professor and Me

Professor Lalzoi waits patiently for me to leave his office.

This week I visited the National Military Hospital’s ophthalmology department and met Professor Lalzoi, a 74 year-old Pashtun Afghan who claims he is the oldest physician at the facility. He speaks no English but is fluent in Russian as he trained for ophthalmology in the Soviet Union at least twice in the past. The Professor appeared to barely tolerate my presence. He’s a reticent man by nature, apparently, and when I tried to engage him on topics outside of medicine, such as the Afghan military and politics, he gave curt answers loaded with subtextual emphasis on the corrupt nature of many things Afghan and my unbelievable temerity for broaching the topics. He didn't exactly cotton to my suggestion that he run for president in the upcoming election, even when I reassured him that at least one 70-something candidate is de riguer in American presidential elections these days. I’m sure we will be good friends before my departure from Afghanistan.

A few patients arrived to break the uncomfortable silence between the Professor and me. The young boy in this photograph has strabismus, or crossed eyes, because he is far-sighted (hyperopic) and exerts such vigorous focusing power (accommodation) that one eye turns in. His father, an officer in the Afghan Army, explained that his son had lost his glasses. (Kids around the world are all the same.) The father then had his son come shake my hand. I know enough Dari to ask “What’s your name?” and the boy seemed so surprised when he heard Naame taan chees? from me that he couldn’t respond. (Then again, he might have understood nothing from my stab at Dari, leaving him to wonder what language I was speaking.) The father was happy to join us for a photograph, and then a technician put dilating drops in the boy’s eyes for the upcoming exam. That medication stings when it hits the eye, and most children I have treated start shrieking after the first drop and thrash about trying to stop the dose destined for the second eye. This boy simply put his head down and rubbed his eyes a bit. These Afghans are tough.

The Professor wanted to confirm the child’s spectacle prescription before writing an order for glasses, and when the boy’s eyes were dilated Prof performed a skiascopy examination in a dark room with a lamp using a few tools I have never seen before; but he was able to determine from the reflection of light off the boy’s retina the refractive error of the eyes and, thus, the proper prescription. I watched and thought the position of the boy with his father next to the lamp in that otherwise dark room might make for a great photograph. They both agreed to pose for me, and I took the photograph below.

The other two patients I saw with the Professor were both severe eye trauma cases. A boy who appeared to be nine years old earlier in the day had taken a pellet to his right eye after a friend of his fired a gun near his face. He had no pain in the eye, but no vision either. His cornea had a laceration visible upon simple inspection, and an x-ray showed a small metal object lodged in the socket behind his eye. He needed surgery later that morning to seal the eye, but it likely will never regain vision. His blindness is due to the negligent discharge of a firearm. Many Afghans have told me that thirty years ago very few people owned guns and Afghanistan was much safer than today, as it seems every family owns a weapon.

I also saw a soldier who had suffered severe facial and torso trauma from an explosive device that detonated near him recently. He was groaning and grimacing the entire examination (which was mercifully brief), but I was able to see that the iris of his right eye was incarcerated (i.e. stuck) in a laceration of his cornea. He, too, needed surgery to release the iris fibers and sew the eye shut. I went by the operating room when another ophthalmologist, Dr. Abdulmanan, was preparing the soldier for surgery. I’m not sure what type of anesthesia they use for eye surgery here, but he needed more of whatever he was getting as when I peeked into the operating room he was writhing on the table and kicking his feet into the air. Maybe he wasn’t fully sedated yet. I hope that was the case. There’s no way Dr. Abdulmanan could have done surgery with the soldier moving so much.
Thankfully, I had to leave the hospital about then. I find that I don’t really enjoy the company of patients in agony. That’s the milieu of other surgical specialties, such as orthopedics. You may know that the definition of an orthopedic surgeon is "someone who has a high tolerance for other people’s pain. "