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.