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.

Friday, August 8, 2008

The European Face of Afghanistan

Samsheen’s friends clearly relish the opportunity to harass him about his European countenance. I noticed him immediately when he was standing with a group of Afghans whose features otherwise corresponded with my expectation of the typical Afghan visage: slim, elongated faces with stark noses, brown skin and dark eyes framed by black hair. But Samsheen is fair, with light green eyes. He’s even balding. Surely, I thought, this guy must be a distant relative of mine. His Afghan friends were thinking the same, as they pushed Samsheen over to me exclaiming “Look! He is European face! He does not look like Afghan.”

If you look survey the Afghan population, you will notice in a minority of the people what geneticists call the phenotypic expression of Western genes: light skin, pale eyes, occasionally red hair. These features may have entered the Afghan population when the Greeks, under Alexander the Great, marched across Afghanistan and then left Westerners in south Asia to administer the new territories. Alexander’s Hellenistic empire eventually fragmented, but the Greeks already settled in the far eastern province of Bactria, in present-day northern Afghanistan, maintained their culture and influence – and their European physical features. Archaeologists have long speculated that the spectacular ancient city of Balkh in northern Afghanistan was a Greek stronghold and a center of Hellenistic culture on the eastern frontier of Alexander’s empire. Excavations as Balkh have never uncovered conclusive evidence that the city once was a thriving, transplanted Greek city; but the French in 1963 found the lost metropolis of Ai Khanum in northeastern Afghanistan, and its ruins contain traditional Greek structures such as a gymnasium, theatre and a temple to Zeus.

Archaeologists studying Ai Khanum determined that the city perished in flames in the second century B.C. Further study of the site ended abruptly in 2000 when the ruling Taliban reburied the site with bulldozers, perhaps as a practical exercise in the exorcism of history and the non-Islamic foundations of Afghanistan shortly before they blasted the enormous, fabulous and irreplaceable Buddha statues carved into a sheer cliff wall in Bamiyan. But the Taliban were only the latest of a seemingly endless procession of fanatics hell-bent on pillaging Afghanistan and displacing its people. Ai Khanum probably fell to invading Scythians from middle Asia who swept south and west into territories ruled by Greeks and Persians.

The Greeks who presided over Bactria for a few centuries most likely had NOT invited the indigenous peoples into the local baths and Hellenistic festivals the ruling Greeks had replicated on the eastern Asian frontier; so when the Scythians came marauding from the north, the locals provided scant cover for their rulers, and many scholars believe the Greek population of Bactria literally took to the hills. Academics surmise the Greeks quickly scattered and hid among the population of the rugged Hindu Kush mountains and its myriad hidden valleys, evading the invading hordes further north and mixing into the indigenous population as if they had always belonged. It must have been carpet-bagging on a grand scale, as if every aspiring politician in the US suddenly moved into New York State seeking acceptance and eventual office.

Until the late 1800s, most people in northeastern Afghanistan adhered not to the Islam that infatuates the rest of the country, but to polytheistic religion practices very similar to those of the ancient Greeks. (Most Afghans, until fairly recently, referred to the area as Kafiristan, or The Land of Infidels.) When scholars considered that fact, along with the existence of entire villages of light-eyed, tow-headed residents in the area, they concluded that the fair-featured Afghans of today are descendents of the invaders who marched with Alexander, or the Greek Bactrians who ruled in northern Afghanistan afterward. Linguists might argue that the tribal language of the area has a foundation that predates the Indo-Aryan tongues that dominated the region, thus pegging the people as possibly the original inhabitants of the area: Not transplanted Greeks, but inhabitants of the area for time immemorial, and a people who never bothered to join their neighbors in the pre-historic migrations to Europe. But today the popular belief among educated Afghans is that the flaxen-haired among them are the progeny of Alexander and his followers.

Samsheen himself has no idea where his family tree is rooted. He told me he is from Kabul, not northeastern Afghanistan, and that most men in his family look like him. He seemed a bit uncomfortable with the attention I paid to his physical features, but he did smile when I informed him that we might be distant cousins, and that his male-pattern balding in the West would be considered a sign of intelligence and virility.

Sunday, August 3, 2008

Afghan Army Physician Recruitment Strategy: A War with Pakistan

The roomful of Afghan medical students disagreed amongst themselves on many topics. The group argued over the theory that the Americans, and moreso the British, secretly support the Taliban while publically posing as opponents to the insurgents. They argued over the salaries they might command upon graduation from medical school from the various non-governmental organizations (NGOs) and coalition forces seeking interpreters, jobs that offer more than the average monthly salary of a government or military physician (which range from $50-$250), but not the $1000-$2000 a few students proclaimed they would earn. (One of my interpreters, he a recent medical school graduate, informed me that the students expecting a monthly salary anywhere close to three digits after graduation were “dreaming.”) The students also debated the virtues of employment with the Afghan Army, the topic I truly wanted to cover at the meeting as one of my projects is a physician recruiting campaign for the army; and I was using these students, most of whom were civilians but a few of whom were already committed to military service, as a focus group to determine why so few medical students consider the army, which suffers an acute shortage of physicians, as a career path.

Of course, I knew already why most of the students had no interest in military service. Many of them consider the military salary laughable. Also, they anticipate that once committed to military service, shortly after graduation they will be assigned to a combat zone far from their homes. Most of these students live in Kabul, the most cosmopolitan of Afghan cities, and sending them anywhere outside the capital would elicit the emotional response of a typical New Yorker after he learned of an impending transfer to Arkansas. In restive provinces such as Kandahar, Helmund and Khost, they would risk danger not only from conventional battles, but from societal elements hostile to the army and the central government in Kabul. (Afghan military personnel often wear civilian clothes when traveling to and from their jobs – or even while on the job – as they fear they will be attacked by insurgents if identified as military.)

But even the students most stridently opposed to military service assured me that they would voluntarily join the army if the government of Afghanistan declared war on neighboring Pakistan.

I have encountered almost daily a pervasive Afghan resentment for Pakistan. Afghans believe, correctly, that much of the terror perpetrated on their country is the result of insurgent training and organization in the tribally controlled Northwest Territories of Pakistan. The area is heavily populated by Pashtuns, the dominate ethnic group in Afghanistan and a people separated by an international border dictated by the infamous Durand Line (drawn by Great Britain in 1893 and another troublesome vestige of that bygone empire). Afghan mujahedeen who fought the Soviet invasion of Afghanistan organized there, and the Taliban now utilize the area to train and launch attacks across the border into Afghanistan. Many Afghans interpret the unwillingness of US forces to cross over the border to eradicate the Taliban from that thumb of Pakistan as tacit American support of the insurgents. These Afghans reason that the US routed the Taliban from Afghanistan in a couple of months, and that we would do the same if we invaded Pakistan’s Northwest Territories – if we really wanted the Taliban gone.

The recent bombing of the Indian Embassy in Kabul has done nothing to improve Pakistan’s reputation in Afghanistan. At least forty Afghans died in the blast, and hundreds of others injured. The bomb damaged much of entire city block. Immediately after the blast, Afghan authorities accused the Pakistan intelligence service of assisting the insurgents who detonated the explosive targeting Indian diplomats. Pakistan denies the allegation, but historically Afghanistan has been a land where rumors, intrigue and duplicity serve as political currency; and it’s difficult to convince most Afghans that its neighbor was not involved in that terrorist act given Pakistan’s past tutelage of the Taliban and its enmity of India.

A prevailing belief in Afghanistan, perhaps justifiable, holds that Pakistan desires an unstable western neighbor. Pakistan and India remain just a few bullets shy of an all-out war, and many Afghans believe that Pakistan fears a united Afghanistan would mean trouble on the Pakistan’s western border in the Northwest Territories where the Pashtun population sits split by the Durand Line. Historically, the Pakistani Pashtuns (and Baluchis farther south) associate with their Afghan brethren, not the dominant Pakistani Punjabis. The Pakistani government exercises little influence now over these lands, as they are the domain of tribal leaders devoted to custom (and their people on the other side of the Durand Line) instead of an affiliation with Islamabad. If the United Nations were the NCAA, and Pakistan a major Division I university fielding the Northwest Territories as a football team, the UN would sanction Pakistan for loss of institutional control.

Afghans I have met also claim that Pakistan wants to keep Afghanistan poor and underdeveloped in order to save a market for cheap, second-rate Pakistani goods that flood the market here. The adjective “Pakistani” is used as a pejorative to describe inferior products, such as “this Pakistani air conditioner lasted only six months” or “that damn Pakistani medication only gave me a stomach ache.” No other country’s exports invoke consumer antipathy more than those of Pakistani. The Chinese are rumored to unload inferior and most likely dangerous goods unto unsuspecting Afghans, but not since Genghis Khan has China loomed as a martial threat to Afghanistan and I haven’t heard anyone in Kabul clamoring for military action against the Red Giant.

I wouldn’t want to be in Kabul should Afghanistan and Pakistan come to blows, even if that conflict would bolster my army physician recruiting efforts. I think it would be suicidal for the Afgham Army to strike at the Northwest Territories at any time in the near future. And I don’t think the US, which still bolsters, trains and maintains the Afghan Army, is ready to commit forces to combat in a third country. Just as unlikely: That a significant number of newly graduated medical students soon will commit to serve in the Afghan Army. A more sobering reality is that many of the new physicians will not even serve their countrymen as clinicians, but will scatter to jobs as interpreters and NGO employees, thereby leveraging their English skills and educations for decent salaries instead of laboring in a national healthcare system whose employee benefits by comparison leave US Medicare physician reimbursement offerings looking like the gifts of a cornucopian horn.