Monday, February 16, 2009

Lessons in Cultural Differences

Chance Wayne: We’ve come back to the sea.

Princess: What sea?

Chance: The Gulf.

Princess: The Gulf?

Chance: The Gulf of misunderstanding between me and you …

                              Tennessee Williams, Sweet Bird of Youth

A group of Afghan Army medics recently quizzed a colleague of mine by asking him to give priority to the following vehicle processions: a wedding party, a funeral convoy, the presidential escort team, and an ambulance traveling with a casualty. The Afghans wanted to know who the American thought was most important and most deserved the right of way should they be encountered on the road. My colleague responded quickly that the ambulance was the first priority, with the presidential vehicle likely second, the funeral procession third, and the wedding party least important.

The Afghans were aghast. They argued that a wedding is the most important event of a person’s life, and that it was only right and correct and fitting that the wedding procession deserved priority over all other groups. The vehicles carrying the dead and the deceased’s relatives would be the second priority, as the funeral signifies that a person is going to meet Allah (apparently the most important moment in a person’s death). The Afghans rated the presidential convoy as the third most important since they carried the leader of the nation. The ambulance, they insisted, was certainly the least important of the processions. The person inside was injured already, they argued. The victim’s fate was more in the hands of God than those of the paramedics and the physicians the casualty might see if newlyweds and dead people didn’t completely block access to local medical care. The Afghans seemed to believe that clearing a path to the nearest hospital would do little to improve the injured person’s chance of survival.

After I heard this story, I began to think strategically on how we could improve emergency medical care in Afghanistan. My first thought was that we should paint and decorate all ambulances to resemble a bride’s vehicle. And maybe we could add edifices to the Afghan hospitals so they would have the outward appearance of one of the ornate wedding halls that are omnipresent and very popular here for nuptials celebrations. A longer term goal would be to ease the sexual repression and frustration that add so much social (and physical) imperative to the wedding (and the wedding night).

All of my thoughts, however, and all of my strategy might very well prove foreign to the many Afghans. After all, we would not agree that even a blushing bride should wait out a rushing ambulance if they arrived simultaneously at an intersection. The Afghans would likely be stunned to hear that I have devout Catholic friends who no doubt would call a halt to a wedding reception to recite a short prayer for the injured should they even hear a distant siren wailing. The difference in how Americans and Afghans think sometimes is quite startling. Hypothetical scenarios such as the aforementioned vividly illustrate the contrast.

I think Americans and our Afghan colleagues can bridge differences as we work together to improve the lot of the average person here, but contrasting sociocultural attitudes, beliefs and priorities often makes the work difficult. Recently a group of Afghan Army colonels were discussing with their American colleagues a proposed system of casualty evacuation from a battle site. The Americans assumed that serious casualties would be transported for care first, followed by the less seriously wounded, and then the dead.

The Afghans colonels were silent at the beginning of the discussion, and very polite to consider the American plan; but then they abruptly inserted themselves into dialogue when, from their perspective, the American proposal proved itself to be prima facie ridiculous. The wounded, they stated, are important. But the dead, they insisted, are more important. Of course the dead soldiers would be evacuated first from the battle site, the Afghans insisted, and returned to their homes or another appropriate location for the quick ceremony and burial that the Islamic tradition dictates.

I’m not sure how you argue against the Afghan colonels on this point. It’s not easy to argue against what someone else accepts as faith, as faith is not always beholden to intellectual reason. I probably could not convince a proponent of intelligent design that there is nothing notable at all in the construction of the human pharynx where our food and air can mix; and that either element can create a disturbance quite easily by taking the inappropriate route further south into our bodies. Or that a woman’s canals for defecating and birthing are perilously close together. There’s nothing objectively intelligent at all in these and other anatomical “designs” of the human body.

Biological evolution can certainly explain their current construction. But to the intelligent designer who refuses to believe the theory of evolution, faith is more important than objective fact. In fact, faith itself often sets the framework for what can and cannot be accepted as fact.

Motivating the Afghans to create what we, the Americans, feel is an appropriate healthcare system will remain a frustrating endeavor until we accept the fact that the Afghans don’t always believe and value what we believe and value; nor are many of them especially eager to adopt our cultural attitudes and ways. The American expectations here might be the major source of confusion and frustration, even though we often consider the response of our Afghan colleagues as the most challenging issue.

I’m no expert in cross-cultural dialogue and learning, but I’ve seen enough during my year in Afghanistan to realize that this place is different – very different – from what I regard as normal and functional. We need to recognize and address these differences if we expect our work to be successful.

But back to the wounded Afghan soldier who sees a dead buddy evacuated before he gets transport for treatment of his internal bleeding: My advice to him is to feign death to ensure quicker evacuation.

Wednesday, February 11, 2009

Latest Taliban Atrocity: Coordinated Murderous Attacks in Kabul

At 09:45 yesterday I had just completed the routine safety checks we perform on our armored vehicles before we leave base when I heard the unmistakable sound of gunfire fire nearby. My colleague Phil and I waited a moment in silence, but we heard nothing in addition to the initial few short bursts. We got into our vehicle, left the base and drove two miles to the National Military Hospital where we had work to do. We did not know that the gunfire I heard came from the Afghan Ministry of Justice building which was under attack by Taliban insurgents.

We were diverted from our usual route to the hospital when a secure road that runs from my base to the entrance of the Presidential Palace was closed. Afghan guards at the security control point were placing steel barriers in the road as we drove up expecting to drive through after showing our identification cards. Instead, the guards motioned for us to turn around. I assumed that President Karzai was leaving the Palace, as the route typically is closed when he travels. I did not know that the Ministry of Justice lay on the other side of the Palace grounds, and the guards at the checkpoint were securing the area in response to the nearby attacks.

At the National Military Hospital we parked near the emergency room entrance, where a small crowd of hospital staff had gathered outside. This was unusual. An American nurse mentor told us that the hospital had planned a mass casualty exercise and that they must be executing the drill this morning. A few seconds later, a disheveled four-door sedan rolled around the corner of the building toward the emergency room entrance. Every one of its windows, including the windshield, was shattered, and the front bumper was hanging askew. The paint on the car looked like it had been sand-blasted. I told my colleagues “I don’t think this is a drill” a few seconds before the hospital staff pulled a limp body from the back seat of the sedan.

Several soldiers jumped into a few of the army ambulances parked nearby and sped off. One of our interpreters got a call from his father, who was walking near the Ministry of Justice building when the attack began, with the news that a suicide bomber had detonated himself and his explosives at the ministry before several armed insurgents stormed the building. The Afghan media initially reported that six government buildings had been attacked by militants. Later I learned that insurgents had bombed and laid siege to two national ministry buildings in addition to the department of corrections building.

Yesterday morning, shortly after the attacks began, no one knew exactly who had been struck or what site, if any, would be next. In that tense atmosphere of anticipation and dread, I recalled my emotion on September 11, 2001 when I watched the second of the World Trade Center towers fall, and learned that an airplane had flown into the Pentagon. I remembered feeling flat and helpless that day, when all I could do was watch CNN as the newscasters tried to make some order of the events unfolding.

I didn’t stay at the military hospital very long. My commanding officer called me and ordered all US military medical mentors to leave the hospital immediately and report to the safe US compound adjacent to the hospital grounds. The military hospital is a prominent institution in Kabul and a likely site for attack. US military personnel throughout Kabul were ordered off the streets and onto secure bases, presumably until the scope of the attacks became known. Even though three sites in Kabul already had been assaulted, Taliban spokesmen were telling media sources that several other suicide bombers were roaming the streets of Kabul looking for targets. Most of Kabul went indoors.

Just before I left the hospital an ambulance returned, and the medical staff lifted from the rear a stretcher carrying the limp body of a boy no older than ten. His clothes were tattered and his exposed skin was burnt. He didn’t move. When the medics transferred him to a gurney his body gave no resistance. He simply rolled like a sack of potatoes responding to gravity. He displayed none of the reflex and muscular rigor we expect from a young human being. The Afghans rushed him into the hospital. I’m certain he was already dead.

I have not been completely dead to my emotions while in Afghanistan, but you witness so much poverty and desperation and cruelty here that these scenes become routine. You expect to encounter them most of the days you venture around the country, and the expectation and unfortunate familiarity keep your emotions in check. The scenes can still impact you, but more subtly as you arrive upon them again and again.

For some reason, however, I had a more visceral reaction when I saw that burned, dead boy. I’m a physician and have contacted dozens of human bodies traumatically amputated and gouged and scorched and bleeding. The sight of bodily trauma, no matter how severe, doesn’t bother me. My medical training leads me to approach such patients clinically in order to determine what needs to be done for treatment and intervention. But when I saw that innocent young Afghan boy after Taliban insurgents had murdered him, I felt both anger and an immense sadness welling up within me.

My sadness is for the Afghan people, who must endure the violence perpetrated by madmen, self-proclaimed liberators, who have no qualms killing the very same Afghans and Muslim they are fighting to “free.” It’s no surprise that the Taliban attacked the buildings housing the ministries of Justice and Education yesterday, as the insurgents have no sane concept of or need for the ideals espoused by those agencies. The intellectually and spiritually barren mindset of the Taliban is something to despise. The actions of these men should provoke outrage in anyone possessing even the thinnest veneer of human decency.

I turned to Phil as we walked away from the hospital and said “The people who did this are animals.” They must be stopped.