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.

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