Tuesday, July 15, 2008

An unusual week, even for Kabul

The National Security Department (NSD) is the Afghan equivalent of a merger of the CIA, the Secret Service and Department of Homeland Security. The NSD has 14,000 Afghan employees, and has its own hospital in Kabul to provide them medical care. Most Americans, myself included, may wonder why a federal government department, even a major department such as the NSD, would be in the business of providing direct medical services to its employees. The answer, I’ve learned, is two-fold. First, the care provided by Afghan’s public hospital system is subpar to non-existent. Therefore, federal department ministers insist on clinics and hospitals devoted to the care of their own employees. Secondly, these same ministers wield enormous prestige and power by controlling their ministries’ medical treatment facilities.

Many Afghans report that this system is part of the “Russian Model” (a common phrase usually uttered by Afghans with unconcealed contempt and disgust) of leadership and government imported during the 80’s when the Soviet Union occupied the country. And the spectre of that cruel decade continues to haunt Afghanistan today: even though the Soviets physically departed in 1989, their nefarious influence lingers in the corruption, bureaucracy and mistrust that continues to keep the country crippled.

But back to the medical care issue. You may be asking yourself: Wouldn’t this proliferation of an essentially private ministerially controlled hospital system create a healthcare delivery model in Afghanistan that is two-tiered, with those connected to government ministries enjoying care much better than those Afghans (the powerless majority) dependent on the underfunded, understaffed, poorly equipped, dirty and decrepit public hospitals? And you would be asking the correct question, and the answer to your question would be: Yes, that’s exactly what’s happening in Afghanistan.

I began last week with a visit to the NSD Hospital in Kabul, and I saw what was by far the nicest Afghan government medical center I have toured since arriving here four months ago. Our guides informed us that the Turkish government built and equipped this hospital for the NSD. I’m not sure why the Turks took on this ministerial hospital as a project. Perhaps because it was a relatively small and defined initiative whereas propping up the Ministry of Public Health, which is responsible for the healthcare of the majority of Afghans, would be a more complicated, frustrating and expensive project. And I must admit that the Turks did a good job: the facility was spacious and clean, with modern equipment for surgery, child-birth, laboratory testing, radiology, physical rehabilitation .. it even boasts a contemporary dentistry and dental surgery suite.

The provision of advanced medical care in this facility with such modern, sophisticated equipment unfortunately is limited by the Afghan medical personnel’s unfamiliarity with most of the machinery. The laboratory has automated analyzers still in plastic, many of the computers have never been booted, the ultrasound machines simply stand sentry in the radiology suite … The Afghan physicians at the hospital invited a group of American medical professionals for a tour and to request that we assist in mentoring the staff on the use of all the high-tech equipment that suddenly surrounds them -- and most of which is completely foreign to their professional experience.

No sane person would begrudge Afghan medical professionals the equipment common to any American community hospital, but foreign donors who foot the bill for MRI machines, electronic patient databases and advanced laboratory capabilities (of what value is PCR in Afghanistan today?) not only ignore the basic medical needs of the typical Afghan – immunizations, prenatal care, midwifery services, childhood nutrition – but they further enable the more privileged and positioned Afghans to sequester the best care for their tiny fraction of the population. And, as mentioned above, much of this foreign investment in the latest technology is foolish: Few Afghan medical professionals are familiar with an automated blood pressure cuff, but some of the well-funded hospitals here have internal automated defibrillators sitting (unused) on the shelves.

Two days after I visited the NSD hospital, it served as the primary triage center for the hundreds of Afghans wounded in a bombing outside of the Indian Embassy which sits just a short distance from the medical center. The blast devastated an entire Kabul block. I was at my desk five blocks from the site when I heard the explosion and saw the windows of my building shake. Press accounts reported approximately forty people dead, most of them Afghans. Some citizens of Kabul claim many more died. A local television broadcast carried footage of an Afghan man as he recounted how he left his wife and two children on the street while he entered the Indian Embassy to secure visas. He survived the bombing, but back on the street he could find no trace of the rest of this family. They were, quite literally, obliterated by the blast.

So many people were killed and injured that the Taliban claimed it had nothing to do with the devastation, although few people believe those insurgents are innocent. When their attacks claim far more innocent lives than they anticipated, the Taliban has a habit of disclaiming any responsibility for the carnage. Afghan officials quickly accused Pakistani intelligence, long associated with the Taliban, of supporting the attack, which was directed at Indian diplomats. Already Afghan leaders are simmering over the safe haven given to Taliban fighters in the Northwest Territories of Pakistan, where they train and then stage incursions across the border into Afghanistan. I’m wondering if the incident will fuel greater tension or even war between Afghanistan and its purported enemies in northwest Pakistan; or even between Pakistan and India, two rivals who historically have needed little encouragement to begin shooting at each other.

The bombing so close to our base left most of us a little tense. The blast was a reminder that travel anywhere in this city and country is dangerous, but as we are on a reconstruction and development mission almost everyone at my command regularly drives around Kabul and environs to attend to our projects. So we were lucky at week’s end to host some visitors who would provide a necessary distraction from the ugly events of war: Roger Goodell, the NFL commissioner, and two Dallas Cowboy Cheerleaders.

The USO group that visited my base also included Osi Umenyiora, defensive end for the New York Football Giants and one of the players primarily responsible for the Giants Super Bowl victory in January. Big Osi was wearing his Super Bowl ring, which is the size of an anvil, and gladly offered the ring to Giants fans so they could take a photograph with him while wearing the championship jewelry. Drew Brees, a graduate of Purdue University and current quarterback for the New Orleans Saints joined Umenyiora, as did Milo Ventimiglia, the lead actor in the television show “Heroes.” I have never seen “Heroes,” and in fact when I saw Ventimiglia strolling around base the afternoon of the visit I thought he was one of the many Afghan interpreters who work here. Even a few of my Afghan friends agreed that he looked like he could be Dawood Najool from Kandahar.

The line for photographs with the group was very long, and I was already late for my weekly poker game, so I didn’t get to chat or pose with any of the celebrities. I need to apologize publicly to my mother for not getting a photograph with Brees, as she is a rabid Purdue University fan. Also, I missed the opportunity to thank Umenyiora for taking out the Patriots in the Super Bowl, thus ruining the loathsome Pats’ quest for a perfect season and thereby earning the gratitude of the majority of the US population living west of Waterbury, CT.

Finally, I regret not getting a few moments alone with the NFL commissioner, Roger Goodell, as I really wanted to ask him why he allows Patriots’ coach Bill Belichick to roam the sidelines looking like an indigent in a hoodie sweatshirt with tattered sleeves.

Photograph: A soldier poses with the USO group. He's wearing the Super Bowl ring of Osi Umenyiora, who stands behind him.

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