tag:blogger.com,1999:blog-2889483793949238612024-03-13T00:16:34.619-07:00Afghan RonnyRumor, tall tales, hearsay, perspective and spot reporting from a military physician deployed to The Islamic Republic of AfghanistanRonald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.comBlogger76125tag:blogger.com,1999:blog-288948379394923861.post-73421472107286535962009-02-16T09:09:00.000-08:002009-02-16T09:09:56.064-08:00Lessons in Cultural DifferencesChance Wayne: We’ve come back to the sea.<br />
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Princess: What sea?<br />
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Chance: The Gulf.<br />
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Princess: The Gulf?<br />
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Chance: The Gulf of misunderstanding between me and you …<br />
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Tennessee Williams, <em>Sweet Bird of Youth</em><br />
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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. <br />
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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. <br />
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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). <br />
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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. <br />
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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. <br />
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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 <em>prima facie</em> 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.<br />
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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. <br />
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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.<br />
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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. <br />
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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. <br />
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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.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com1tag:blogger.com,1999:blog-288948379394923861.post-83822568481484634162009-02-11T19:12:00.000-08:002009-02-11T19:17:28.113-08:00Latest Taliban Atrocity: Coordinated Murderous Attacks in KabulAt 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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />I turned to Phil as we walked away from the hospital and said “The people who did this are animals.” They must be stopped.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-47129442807595892522009-01-31T21:30:00.000-08:002009-01-31T21:38:52.571-08:00Afghan Ronny in the Social Justice Press<i>Almost twenty years ago, when Afghan Ronny was in his early twenties, he maintained a lifestyle more attuned to his social and political ideals. At the time, he also was unafraid of personal poverty. Three of those years he spent with the Jesuit Volunteer Corps: East, a Catholic service organization whose work is defined by four tenets: social justice, simple living, community life and spirituality. During his tenure with the JVC, Afghan Ronny never envisioned himself as a physician, and certainly not a military officer. Luckily, the JVC community has not ostracized him for moving into the financially lucrative field of medicine, or joining the armed forces. (The Jesuit volunteer community is populated by scores of lovable peaceniks who abhor any kind of violence.) In fact, the organization recently requested an article for JVC: East periodical, <b>Journeys</b>. Below is the submission, included here without the minor editing needed for publication. (Afghan Ronny is never short of words.)<br /></i><br /><b>Prayer in a Time of War</b><br /><br />Recently a coworker, whom I will call Susan, recounted for me how a young soldier she knew, whom I will call Kevin, always visibly prayed for the safety of himself and his fellow soldiers before they departed their base in Kabul, Afghanistan for convoy operations. The major threats to the American military in Kabul are roadside explosives and suicide bombers that might be waiting to attack your vehicle as you traverse the congested city. We travel in armored vehicles with heavy personal protective gear and loaded weapons every time we leave our bases. Kevin’s fellow soldiers certainly recognized the dangers of every convoy they undertook, but apparently delighted in mercilessly teasing him for his overt spirituality.<br /><br />Susan, a devout Christian, continued to tell me how Kevin’s comrades hit a bomb the first day Kevin was away on leave, when no prayer preceded the convoy vehicles’ departure from their relatively safe, fortified compound onto the Kabul streets. I saw a wry smile on Susan’s face as she told the story, and sensed her true message: <i>Don’t underestimate the protective power of God toward those who pay the Lord homage</i>.<br /><br />I had a visceral and much different reaction to the story. If God is merciful, I asked myself, why would Kevin’s fellow soldiers be more at risk without Kevin and his prayers? Because Kevin prayed openly for safe passage, did he serve as something of a protective totem for the convoy group? Is the intervention of God into the world today that simple? I doubt it.<br /><br />You don’t have to look to Afghanistan for evidence that God’s mercy, love and justice manifest themselves in this world much differently than what we might expect or even understand. Today I read of the death of Nequiel Fowler, a ten-year old from the southside of Chicago killed in the crossfire between two rival gangs at war at 4:30 in the afternoon on the block where she lived. Her younger sister Valerie, blind from eye cancer, was with her but unharmed. Did Nequiel forget to say her prayers the night before? Did her family neglect to petition God for safety? Was Valerie a “better little girl” and therefore able, by the grace of God, to dodge the bullets?<br /><br />Such questions are rhetorical at best, and possibly even cruel. Nequiel was an innocent girl trapped in a brutal world where parents often are afraid to allow their children out of the house to play as armed drug dealers and dangerous gangs infest the streets. She was not responsible, by acts of commission or omission, for her own death, just as her sister is not responsible for the cellular chaos that produced the neoplasms that disrupted her vision. Nequiel’s predicament and ultimate death are disturbing testimony to the injustice human beings will inflict on one another. And although the overt social abuse Nequiel withstood came compliments of her thuggish neighbors, as a society we are responsible for marginalizing entire populations into decaying, oppressive sectors of our cities and countryside where crime, abuse and injustice grow inextirpatable roots.<br /><br />In Afghanistan, when suicide bombers and other insurgents attack foreign forces in the country, local citizens often suffer most for the brutality of the event. Recent bombings in Kabul have killed and maimed many more Afghan children and adults than foreign soldiers. The Afghans killed and wounded were the victims of a war, a conflict they likely found necessary to tolerate but not support. They simply were walking to school or work or to the market at an inauspicious time. No prayer before the blast would have saved them from their suffering, because a deranged human being, not God, decided they were insignificant and expendable.<br /><br />Every time I travel through Kabul and the outskirts of the city, I see thousands of large families living in small mud huts. They don’t enjoy even minimal medical care. Many suffer from malnutrition. For every woman covering herself with a burka in public, another young wife is restricted from even leaving her home. Children play in the same foul water that they drink and use for bathing. Local markets recently began selling bread scraps as the price of food has risen astronomically. Trucks dump raw sewage into a rank field near the center of the city. And I am describing Kabul, the most urbane, developed metropolis in Afghanistan.<br /><br />My job in Afghanistan is to assist the Afghan Army in developing a medical system able to provide adequate treatment for soldiers and their families. The goal of US military personnel working as mentors with the Afghan Army is a competent, self-sustaining military institution that can ensure the security Afghanistan needs in order for the nation to develop, prosper and protect its citizens.<br /><br />I play a small role in an ambitious project that Afghans and foreign advisors have undertaken: The creation of a unified Afghanistan free from internal strife and external oppression. Such an Afghanistan has never before existed. Dedicated people, the vast majority of them Afghans, are addressing social ills that threaten to stifle this new Afghanistan: corruption, poverty, hunger, ignorance, misogyny, indifference, exploitation. These scourges, all too common here, threaten most Afghans much more than do bullets or bombs.<br /><br />I’m not sure what place prayer has in a land like Afghanistan, and in the conflict that surrounds me. Do you pray for protection for yourself when you know that a child living a few blocks from you endangers himself every time he walks into the street? Do you pray for safe passage out of Afghanistan after a tour of duty is complete, knowing full well some woman you may have passed on the street could have been killed by her husband for showing her face to a stranger? Is such prayer too selfish, too smug, and too foolish?<br /><br />Do you recognize that the fight in Afghanistan is a war with injustice, not simply a battle with the Taliban? Do you dare pray for protection and peace in the midst of yet another war that has nothing to do with God, but everything to do with us?<br /><br /><em>Article first published in <strong>Journeys</strong>, the periodical of the Jesuit Volunteer Corps: East, Vol 32, No.1, Fall 2008.</em>Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-72365679566401366242009-01-24T08:29:00.000-08:002009-01-24T08:38:38.784-08:00Afghan Ronny on the RadioI first encountered Indiana Secretary of State Todd Rokita in September of last year at breakfast in the dining facility at Camp Eggers, Kabul. He was a man in civilian clothing whom I had never seen before, and he was reaching for a breakfast burrito on the steam table. “My advice,” I told Rokita, almost reflexively, “is that you skip the burrito.” Most of the breakfast fare here is decent, but not the breakfast burrito. It features what appears to be a soft, flour tortilla shell; but that casing, upon handling, actually feels like the stiff cylinder of cardboard that makes for the centerpiece of a toilet paper roll. Within the shell is a concoction with the consistency of tapioca pudding, the color of aged egg yolk, and the taste of an exotic, spiced chalk.<br />
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Rokita took a burrito anyway, a choice he later regretted; but when he turned to me, surely wondering who the hell was I to have the audacity to tell him what to eat, I noticed he was wearing a baseball cap with the name of my home state, Indiana, stenciled on the front. “Are you from Indiana?” I asked. Rokita looked surprised. I suppose he was waiting for me to tell him that his hash browns were inedible. Instead, he said, “Yes, I am. Are you?” And at that we started small talk, as native Hoosiers are wont to do, and sat down to chat some more while we ate.<br />
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Rokita was visiting US military bases in both Iraq and Afghanistan with a few other state secretaries to investigate if military personnel had adequate access to absentee ballots for the upcoming election. He was delighted to hear that I not only had received my ballot from the Howard County Clerk in Kokomo, Indiana, but that I had mailed it the previous day. I was impressed with Rokita’s professionalism as he made no mention of the candidates on the ballot, or what I thought of the players in the upcoming election. All that interested him was the ease with which I was able to obtain an absentee ballot while deployed in a war zone.<br />
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I met with Rokita later in the day as at breakfast, shortly after he confessed that he should have taken my advice on the burrito, he told me that he would like to meet any other personnel at Eggers from Indiana, as he had gifts of state flags that he would like to distribute. I found a Navy petty officer I know who resides in South Bend, and we joined with Rokita to receive our flags and run them up the flag pole for a photo op shortly before he left the base. As he was departing, Rokita asked me if there was anything his office in Indianapolis could do for or send to the military personnel at Eggers.<br />
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<b>The situation at Camp Eggers</b><br />
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Although Camp Eggers is a base situated in the capital city of a country at war, and although IED strikes and rocket attacks are not nearly as common here as in other more restive areas of the country, danger still exists. Just last week, a suicide bomber with a carload of explosives detonated himself and his load along the perimeter wall of Eggers, inflicting many Afghan casualties in addition to killing one US soldier and severely wounding another. It was the biggest blast so close to home since Eggers was settled as a military base several years ago. Personnel from Eggers cannot leave base unless we are on a trip essential to our work, which means we are restricted to base for much of our time here. I live in Kabul, but I feel that I know only those parts of the city I regularly drive past, and I know those areas only by sight.<br />
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Although personnel at Camp Eggers are for the most part isolated from the rest of Kabul, our existence is not one of discomfort. We have hot meals, usually enjoy hot showers, and can exercise in a well-equipped gym. I must share a room with another officer; but I can buy internet access for my personal use, and a small military exchange here has most of the toiletries I need, along with snacks that I should do without. We even have a Thai restaurant on base, with an authentic Thai staff that looks to be suffering <i>in extremis </i>from the winter cold; as well as a small pizza restaurant. We are comfortable, especially when compared to the military personnel forward deployed to more austere bases found in remote Afghanistan. And even those forward deployed personnel are living pretty comfortably relative to the millions of poor Afghans who regularly go without food, proper clothing, and decent shelter.<br />
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A few times every month military personnel from Eggers embark on a humanitarian mission and visit a needy area of Kabul where we distribute donations of clothing, food and toys sent to us from people in the US. Oftentimes we are lacking toys, so I suggested to Rokita, when he asked what he could do for us, that he recommend his office staff collect toys and send them here so that we would have gifts to distribute to Afghan children. Rokita was obviously touched that I requested toys for the local children instead of comfort items for myself and the other Americans. I can only assume that he didn’t notice the availability of Thai cuisine on base and the stack of Snickers bars on my desk. Regardless, in emails subsequent to his visit, I coordinated with Rokita and his staff the logistics to get toys collected by his office in Indiana to the children of Kabul. I distributed most of the holiday stock his office sent to a refugee camp filled with Afghan families recently returned from Pakistan who were living in the most squalid conditions I have seen since I left the house I shared with six other male friends my senior year at Marquette University. I photographed several of the children with their toys, and sent them to Rokita’s office where they are now posted on the Indiana Secretary of State website at the link below.<br />
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http://www.in.gov/sos/desk/AfghanChildrenToys.html<br />
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<b>A short statement on official visitors to places like Afghanistan</b><br />
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The title of this article speaks of a recent appearance by Afghan Ronny on the radio, an episode I will address shortly. First, though, I would like to give an opinion on the propensity of public officials and military leaders to travel long distances in order to ascertain exactly what is happening in places such as Iraq and Afghanistan where American military personnel are fighting wars. These trips can be categorized as fact-finding missions, or junkets, or boondoggles, depending on your point of view. As a deployed Naval officer who has met, while in theater, his congressman, his home’s secretary of state, and several Admirals with collars full of stars, I support most of these visits. These people are responsible for the policy decisions that eventually determined my deployment to Afghanistan, and they are responsible for supporting me and the overall mission of the US military while I am here. I am not sure what these visits cost the American taxpayer. I’m not even sure if all the visitors I have met traveled on the government dime. But whatever the cost, and to whomever, I applaud the travel.<br />
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You simply cannot fully appreciate the situation here from a chair in the United States. Additionally, a minority of senior public officials these days have military experience. They, along with the senior military officers based in the US, need to see first-hand what a war entails, and how a war progresses. They need to hear stories directly from the personnel who enact the executive and legislative decisions of the country. They need to see how a conflict and US policy decisions affect the local populations that absorb the brunt of any war’s violence. And since these dignitaries all have to fly into the theatre of war on military airplanes, most are able to experience the joy of travel in Air Force C-130s and C-17s.<br />
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<b>Now about the radio appearance</b><br />
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But about my radio spot. A few weeks ago, a staffer from Secretary Rokita’s office contacted me and invited me to participate in a radio show Rokita would host on AM 1430 in Indianapolis. Rokita wanted me to talk about the toy donation program for Afghan children that his office supported, and also to speak about my situation in Kabul. Those who know me are aware that the only thing I enjoy more than hearing myself talk is to hear myself talk to the media. I quickly sought and received authorization from my commanding colonel to participate on the condition that I mention his name and excellent leadership while on the air. I also alerted family in Indianapolis and Kokomo, Indiana to tune into and tape the segment that I was sure would serve as the platform from which I would launch my own media career after broadcasters recognized my eloquence and brilliance. My sister Therese assured me that procuring a tape of my “performance” would be simple, as her husband, my brother-in-law Steve, is the sales director for the station.<br />
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When I called into the show on January 21st and spoke to Rokita during the newsbreak before my segment, he asked if I would mind responding to callers while on the air. No problem, I said, thinking to myself that it was an excellent way to start bonding with my future loyal audience. But I will admit that I also wondered if anyone listening would have questions for me. It’s not like I am a celebrity. Not yet, anyway. But my first few minutes went well. I cannot remember all of what I said, only that I did most of the talking; and when I finally shut my mouth Rokita went immediately to a commercial break.<br />
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I could hear the station staff over the phone during the break, and someone announce that one and then two callers were on hold. Unbelievable, I thought. The residents of central Indiana so quickly have recognized my genius and affability, and are calling to speak with me after only a few minutes on the air. I braced for the first caller, wondering what I might be asked. I rehearsed answers to possible questions about my educational background, my motivation, my idyllic childhood and adolescent years in Kokomo. Then Rokita introduced the caller: Therese, my sister. And she didn’t ask me anything at all, but proceeded to tell the listening audience what a nice and service-minded guy I am. She judges me short on brilliance, but high on benevolence. Not bad, I suppose, and I was thankful for her comments; but I wondered how this use of precious airtime was going to further my budding media career.<br />
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I was able to ramble on myself once more shortly after Therese hung up. Again, I cannot remember exactly what I was saying, only that I was doing all the talking and Rokita, bless him, did not interrupt me. But then, after another monologue of several minutes, I heard a dial tone and realized that my precious connection to AM 1430 was no longer patent. I have no idea when the phone line disconnected, nor what of my disquisition my audience had missed. I furiously dialed to reconnect with the station. I reached Rokita again, and he laughed off the disconnection and told me not to worry about the interruption as he was going to commercial break at about the time I suddenly dropped from the airwaves. I knew I couldn’t let the severed broadcast disrupt my focus and concentration, as my second caller now awaited a conversation with me. Rokita chuckled as he introduced her, saying something like “I think you know this caller as well.” It was my mother.<br />
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Most mothers, having not seen a son for twelve months and surely worrying about him that entire time since he was deployed to a war zone, would probably spend the first few moments of a phone call, even one conducted in public over the radio airwaves, inquiring about her son’s well-being. Not my mom. At least not during this call. She and select friends of hers also had been sending me toys for Afghan children; and, after the briefest of salutations to me, she used her airtime to let central Indiana know what items where appropriate and inappropriate for delivery to Afghanistan. After a minute or so, Rokita managed to verbally muscle both my mother and I into a moment of silence, something that had been nearly impossible for him to accomplish with my family up to that point in the show. He slyly asked my mother if there was anything she wanted to tell the audience about me, perhaps a story of my childhood or teenage years. I quickly interjected at that point, insisting that my mother was to say nothing even remotely controversial. I am a physician and I have a professional reputation to uphold, and my mother maintains a reservoir of facts about me that, if revealed, would cause a congressional confirmation committee to collectively gasp and ask for a recess. Thankfully, another commercial break then intervened.<br />
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I felt obliged to end my segment of the show by thanking Rokita for allowing my family to turn his radio program into a verbal Willy reunion. I also assumed that my brother-in-law at 1430 AM had arranged for my sister and mother to be the only callers on the show. Not so, my sister told me. She did not even know that I would be taking callers until Rokita announced the open phone lines when my segment began. My sister then called my mother, who reportedly was driving around Kokomo with my father as they could get the broadcast in their car but not in their home, and told her to call the station. Both reported that they had no problem getting through to speak to me. I guess I wasn’t drawing as much of the attention of central Indiana as I had hoped.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com6tag:blogger.com,1999:blog-288948379394923861.post-31306496998887191002009-01-12T06:53:00.000-08:002009-01-12T07:01:18.262-08:00Viagra apparently NOT a silver bullet for intelligence agentsThe headline in the Washington Post was sure to draw attention:<br />
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<strong>Little Blue Pills Among the Ways the CIA Wins Friends in Afghanistan</strong>*<br />
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The article reported that CIA field operatives in Afghanistan were distributing Viagra to select elders and chieftains in order to win their favor, and hopefully gain intelligence on insurgent activities and other critical knowledge of the Afghan leaders’ territory. You’ve heard of the effort to win hearts and minds. With this strategy, US intelligence seemed to be moving in a direction that would secure our nation the allegiance of other Afghan organs.<br />
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The story relies on unnamed intelligence officers to corroborate that Viagra is just one of many gifts that an intelligence operative might use to win over an aging yet still influential Afghan. The problem with the report, as several of my own reputable sources tell me, is that it simply isn’t true.<br />
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Of course the CIA itself won’t comment one way or the other on the story. That isn’t surprising, as the Agency’s policy is that it never comments openly on methods used in clandestine intelligence operations. So that fact the Langley says nothing means nothing.<br />
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The striking thing about the article itself, which troubled me when I first read it and assumed its veracity, were the internal inconsistencies. Those alone should have prompted my skepticism over the truthfulness of the story. The reporter quotes a “senior U.S. intelligence official familiar with the Agency’s work in Afghanistan” as saying that operatives use tactics “consistent with the laws of [the US].” Viagra is still a prescription drug in the US, and I doubt if intelligence teams harboring any ideas of dispensing Viagra were prepared to drag a physician around Afghanistan with them; so the quote from this official, which was more extensive and supported the ingenuity of the operatives for thinking “out of the box” and doing “what’s necessary to get the job done” (apparently by stocking up on blue pills for field ops) was itself internally inconsistent. <br />
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This mysterious intelligence official seemed to want it both ways: To both assure compliance with US laws, and yet insure that CIA operatives were free to distribute pharmaceuticals without a license, and likely with little familiarity the drugs as well. <br />
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The official quoted also applauded intelligence agents who “take risks.” If the agents were in fact distributing Viagra to impotent and elderly and likely dehydrated Afghans, then they did enjoy risk, including the risk that the Viagra would suddenly drop the blood pressure of the intelligence source they were attempting to court and leave him on the ground dead due to drastically reduced cardiac output. In Afghanistan, like most other places, the people are more likely to admire you and cooperate with you if you assist them by improving and prolonging their lives instead of killing them. An intelligence operative likely would garner scant information from a village should he return the next day and discover that the local elder died shortly after munching the blue pill left by the American.<br />
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The article quotes a supposed retired operative as saying that the Viagra was not given until the prospective Afghan recipient’s health could be “established.” I am not sure what “established” means here, but I doubt it means the intelligence operative performed a full physical examination on the man and verified blood pressure and other vital signs in addition to reviewing current physical complaints and the Afghan’s past medical history. In other words, I doubt any intelligence agent would have the knowledge or inclination to complete the sort of medical evaluation necessary and expected in the United States before a physician would prescribe Viagra. I don’t know what this former operative is doing for retirement work. I can only hope he didn’t begin a second career in medicine.<br />
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I also hope he doesn’t provide any type of marriage counseling, as this same retired operative states that older Afghan men, often maxed out at four wives as is the Islamic custom in Afghanistan, consider Viagra a tool that can put them back into “an authoritative position” in their marriages. It is not uncommon for rural Afghan men to have wives of different ages. As an Afghan man ages, he often will marry successively younger wives. If a man is hovering around sixty, and sexually not the dynamo he was once when he had only one or two wives and a raging libido, he probably is pleasing his older wives by simply leaving them alone at night. And the younger of his betrothed, I would guess, are happy that a man who resembles their grandfathers is not cuddling next to them with an erection. It seems to me that, from an Afghan female perspective, the miracle of Viagra might be utilized by a husband to introduce not authority into his marriages, but instead punishment. Maybe US intelligence and counterintelligence efforts alike should consider focusing on the Afghan women a bit more, so we don’t lose the females to the insurgents as we ponder ways to (figuratively) stroke their men’s egos and sexual appendages.<br />
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One final thought for any intelligence operative considering the use of Viagra for currying favor with elderly Afghan men: The effects of the Viagra itself are fleeting, as will be the loyalty of any Afghan recipient. The Taliban can procure Viagra from the Kabul bazaars and distribute it around the countryside more easily and with greater effect, perhaps, than can US intelligence agents. The Taliban have a tougher time building roads, dams and electrical plants; and digging wells and instituting agricultural programs for poor rural Afghans. The Taliban’s expertise with such projects is their ability and willingness to destroy them at the expense of the livelihood of other Afghans. I think these initiatives, instituted for the greater good of the community, might be where any US operative wants to spend his time, energy and money. They are the endeavors that will promote peace and security and a favorable view of the US. We need to keep the focus on long-term investment instead of a short-term erection. <br />
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*Washington Post article, December 26, 2008Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com2tag:blogger.com,1999:blog-288948379394923861.post-26082479906120627932009-01-03T08:26:00.000-08:002009-01-03T08:45:11.194-08:00It Cannot Get Much More Desperate Than ThisYou’ve seen the footage on CNN of the refugee camps in places like the Sudan and other war-torn nations. The reports usually feature shots of hundreds of skinny children with dirty faces and tattered clothing; of makeshift shelters constructed of flimsy wood and rope and UNHCR-embossed tarpaulins; of an aid worker at a vat of gruel dishing meals to camp residents; and possibly a medical tent with a red cross on the side with a line of patients waiting, exposed to the elements. The refugee camp I visited recently in Kabul featured the first two: plenty of dirty kids, many of them shoeless, in light clothing even though winter snow has arrived; and housing constructed from scrap sheets of plastic, mud and blankets. Unfortunately, I didn’t see much in the way of food or medical care.<br />
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This camp is a settlement of fifty families displaced by war or poverty. Or both, since both ravage Afghanistan and hundreds of thousands of people continually move to Kabul in hope of finding work and food. I’m not sure if the Afghan government provided the land for this camp – a 200 x 200 yard expanse of dirt near the middle of the city – or if the people here are squatters. It doesn’t really matter much, as many, if not most, of the residents of Kabul are quite poor, and they live on land to which they have no legal claim. They settle on plots of land relished by no one. <br />
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Such as the hillsides. The city of Kabul rests in a valley surrounded by mountains and impressive hills. If this were Hollywood, expensive homes would occupy the highlands, providing fabulous views of the metropolis. In Kabul, the higher you live in the hills, the poorer you must be. No roads climb up the hills. There are no water wells up there. My Afghan coworkers find it unbelievable that wealthy people would even consider a residence in the hills in the United States. When they see a house high on a hill, they think about the daily circuit those residents must make down and the back up the hill simply to fetch fresh water. <br />
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The refugee camp was on flat ground, but it had no well that I saw. The sector of the city surrounding the camp seemed sparsely populated, possibly because the land is so unfit for human occupation. The camp “latrine” was a corner of the settlement designated for waste. I saw no fire wood, only dung balls, rolled from the excrement of the few head of cattle in the camp that the refugees burn as fuel for their fires. For comical juxtaposition, an elaborate wedding banquet hall stood a few hundred meters away, and across the street was a building billed as the “Afghan Economical and Social Development Exhibition.” <br />
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I went to the settlement with two dozen other military personnel from my base to distribute cooking oil, blankets, clothing and toys to the camp residents. Oftentimes these trips can be raucous, as the desperate people, both children and adults, will swarm you and try desperately to grab hold of anything you might be able to offer them. In fact, I left my wallet and keys in my office for this trip, as kids oftentimes will search your pockets for goods while you are engulfed in a crowd of fifty of their friends. Thankfully, though, this group was relatively orderly. The elders from the camp did a nice job of keeping order, mostly by swatting children back from the supply truck as we tried to unload it.<br />
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This place was without question the most wretched human settlement I have ever encountered. I’m not Angelina Jolie, but I’ve seen some pretty desperate communities both permanent and temporary on a few different continents. Yet no place I have ever visited before embodied the perfect storm of malnutrition, disease and foul weather that marked this camp. A few infants in their mothers’ arms appeared obtunded. Every child looked malnourished. Congenital malformations, lazy eyes, and dermatologic maladies were the norm among the children, who played among cows and goats and the droppings that accompanied those animals. A good number of the men had limbs either twisted from untreated trauma, or missing altogether. No one appeared to have bathed in a long time. No one wore clothing proper for an Afghan winter, and if they had shoes they likely were sandals. Everyone bore a rather thick film of dirt on their skin. <br />
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Several families lived in hovels carved from the side of a hill, sometimes featuring a mud brick wall. Those were the prime pieces of real estate. The majority of people lived in tents or shelters made of nothing more than plastic sheeting. None of these residences provided much protection from the cold. None of them had functioning doors. And the temperatures in Kabul have dropped precipitously the past few weeks, with snow arriving just a few days ago. Maybe the cold was what led me to think, as I stood and looked around the camp, that it doesn’t get any worse than this. It couldn’t get worse, because any worse and you simply could not survive. <br />
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We distributed toys to the children and supplies to the adults, but I noticed that I didn’t see much of what we provided shortly after we handed it out. A few boys kicked soccer balls that we brought them, but otherwise you were challenged to see a stuffed animal or any other toy we had provided. I learned from an interpreter that both the children and adults quickly take their new possessions and hide them, probably in their shelters, either to protect them from theft or to preserve them for the future. Most of these people possess little more than what they wear and carry with them each day, and they want to preserve anything new or novel that they acquire.<br />
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Even though I had trouble finding many kids with their new toys, I had no problem finding residents who wanted to pose for photographs. I have written before that most Afghans are proud to pose for photographs, no matter what their socioeconomic or physical condition. The rarely seem to consider an avid photographer a voyeur. In fact, they can get surly and indignant if you <em>don’t</em> photograph them. The only exception to this is that many Afghan women, for purposes of modesty, will shy away from the camera. In this settlement, however, almost everyone waived for me to photograph them. One stately, elderly gentleman held a pose for several minutes while the Americans flocked around him like paparazzi. A father kept herding his children back to the front of their mud hut so that we could get shots of the entire family, including the wife. It was difficult to photograph a solitary child you might find especially cute, because a virtual swarm of other children would enter the frame when they saw you had a camera. <br />
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The snow fell heavier this morning, the day after I visited the camp. I walked to breakfast with a colleague who had organized the trip, and I told him as we entered the dining facility that I was wondering how those poor children in the camp were doing today. He said he was thinking the same thing.<br />
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Note: The internet speed here rivals dial-up velocity circa 1992. I cannot upload photographs of the refugee camp today. I will try again another day, as a few of the photographs will tell the tale of this camp much better than I am able to describe it. Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com2tag:blogger.com,1999:blog-288948379394923861.post-59486677331354260322009-01-01T04:47:00.000-08:002009-01-01T04:53:17.891-08:00A Visit to the Slaughterhouse<strong></strong><br /><strong>WARNING:</strong> If you are a vegetarian, easily disturbed by descriptions of the slaughtering of animals for human consumption, or averse to tales of mammalian blood loss (my friend Joe Gaylord come to mind), I recommend you discontinue reading this post now.<br /><br /><br /><br />I agreed immediately to accompany the preventive medicine officer on his inspection trip to the local Afghan Army slaughterhouse. Several months ago I had seen photographs of slaughterhouses here depicting men with bloody butcher knives in their mouths, cats serving as the rodent eradication force, and sickly animals nonetheless passed as safe for butchering and eventual human consumption. I also eat in the Afghan Army dining facilities occasionally, and the beef, lamb and goat from this particular facility stocks all the army kitchens in Kabul; so I was curious as to the origin of my lunch meat.<br /><br />We first visited the holding yard where all newly acquired animals spend a minimum of twenty-four hours to ensure that they are robust enough to at least eat and ambulate. The cows, sheep and goats in the yard enjoying their last few hours of life when we visited were certainly able to scurry away whenever we ventured close to them for a photograph. The Afghans giving us the tour thought it funny that we would want our pictures taken with a herd of goats, but I’m sure it was just the latest of American behaviors incomprehensible to them.<br /><br />The stockyard smelled like any other stockyard. In other words, it smelled like an animal pen from a Midwest farm, so I rather enjoyed the earthy scent as it elicited pleasant childhood memories of my family visits to the Gethsemane monastery in Kentucky where Uncle Ronny, my namesake, lived as a Trappist monk and worked with the other brothers a very large dairy farm. The farm featured a pen with a bull, and my brother Dave and I would sit on the fence and take in the smell of hay and manure as we waved a red shirt at the beast in an attempt to get him animated. I was rather cautious of the cattle in the Afghan stockyard, as I know from personal experience that taunting can get them agitated; and I was happy to note that they were leashed.<br /><br />The Afghans informed us that they segregate all the animals by sex when they arrive. Afghan culture dictates that men and women rarely socialize with anyone of the opposite sex outside of their own families, so I thought this routine might be an extension of that custom. I also thought it rather cruel to separate the male and female beasts, thus negating the possibility of one last night of carnal pleasure before they were sacrificed for the nutrition of the Afghan Army and its American mentors. Through an interpreter, I suggested to my Afghan colleagues that perhaps they should do something nice for the animals here and allow the males and females to consort together on their last night of life.<br /><br />Attempting to amuse another person through an interpreter is a rather dicey initiative. Oftentimes the interpreter himself will not understand your joke, or perhaps the languages differ so much in vocabulary and contextual imperatives that an extremely witty line in one tongue becomes simply a befuddling phrase when translated into the other. The interlude necessary for the translation of your words is painful enough with regular conversation; but when you’ve told a joke, and are anticipating some display of mirth from your interlocutors, the period during which you wait while your colleagues hear your words in their own language can be excruciating. You begin to fear that what you said was not funny at all to them; or worse yet, offensive. Thankfully, at the slaughterhouse, I had with me a very fine interpreter who immediately laughed when I proposed cohabitation for all animals awaiting slaughter, and every one of the Afghans surrounding me roared with laughter after they heard the translation.<br /><br />What I like about most Afghans with whom I work – good Muslims all of them – is that they like to eat and they love to laugh, even if the humor is a bit bawdy. It’s my kind of Islam.<br /><br />From the holding yard, we went to the cattle slaughtering room. It was easy to find, as approximately fifteen severed cow heads were piled outside the door. The eyes I could see had a rather stunned look, as if the animals were shocked that this was the end. Inside the slaughtering room, men worked at several carcasses of beef, stripping away the skin and fur, pulling out the innards, and sectioning the meat with axes. In fact, the slaughtermen did all of the work with their hands or with a hand ax. I was impressed with the men sectioning the meat, as they obviously were quite skilled and practiced at slicing the carcasses with a simple ax, and they were able to partition the meat nicely.<br /><br />The room itself was cleaner than I had expected it to be. Some of the butchering was done directly on the floor, which itself was not exactly a sterile surface. The USDA inspectors would not have liked that practice, but Upton Sinclair probably would never have bothered writing <em>The Jungle</em> had this been the only slaughterhouse he saw. I remember a neighboring farmer in Indiana who would annually butcher a cow by killing it then hoisting the animal by its hind legs with the front lift forks of his tractor before he disemboweled it. The work in the Afghan slaughterhouse seemed at least as clean and sanitary as that farmer’s, and I remember the fresh beef our neighbor delivered to my mother as tasting delicious.<br /><br />I asked the supervisor how they actually killed an animal, as we entered the room when the cattle had already become simply large sides of beef, and he told me they first tie the legs and then quickly slit the animal’s throat. He then became excited, and told me that he would go fetch a cow and kill it so I could witness the procedure myself. I really had no interest in watching that process, nor did my colleagues who just uttered “Oh my god” after our interpreter told us the supervisor’s intent. I grabbed our interpreter and, luckily, we caught supervisor just as he was making his way to the stockyard. I explained that I really didn’t want to interrupt the routine of the facility, and that although I appreciated his willingness to down one more head of cattle for our edification, the additional slaughter really wasn’t necessary. He understood, thankfully, and then suggested that we move on to the room where they dealt with the sheep and goats. I told him that was just fine with me.<br /><br />As we continued the tour, I joked with my colleague Dr. B-, one of the Afghan army officers who was accompanying us, that the sight of all the fresh meat was making me hungry for lunch. Dr. B- laughed, and as we entered the next room we encountered three freshly slaughtered sheep hanging on a hook, one of which was obviously a male (until recently) as its inordinately large testicles hung down over the abdomen of the inverted carcass. Dr. B- pointed to the testicles, smiled and told me “We will prepare these for you for lunch as you are very hungry!”<br /><br />Dr. B- and I have become friends over the past few months. I was impressed when I learned that he has fathered twelve children, and I always make mention of his virility whenever we meet. After he suggested the testicles for my lunch, I took his hand (an appropriate gesture of friendship between men in Afghanistan) and told him that I would eat them if the meal rendered me as fertile as he is. Dr. B- laughed at my retort, and told me that when this inspection tour was over we must take tea together. He’s my kind of Muslim.<br /><br />There was very little activity in the sheep and goat section of the facility. The workers slaughter a specified number of animals each day, and that morning they had already killed, skinned and sectioned the allotted number of sheep and goats. The supervisor decided, however, that since we were not able to see how they killed the cattle, that he would bring in two sheep so that we could witness the slaughtering process from start to finish. We couldn’t stop him this time. When we learned of his intentions through our interpreter, he already was heading back from the stockyard literally dragging and carrying a bucking sheep that acted as if it knew precisely the consequences of the very near future.<br /><br />I hope, when my time comes, to die a peaceful death, and pass from this world during a night of deep sleep. If I have to die by the knife, however, I want one of the Afghan slaughtermen I met to take me out, because they went about their work as quickly, professionally and humanely as you get when you are killing an animal with a sharp instrument. One man grasped the hind legs of the sheep, and another secured the front legs and upper body of the sheep before he took what was certainly a very sharp knife and, in one smooth motion, slit through the animal’s neck so deeply that the head looked as if was swinging back on a hinge.<br /><br />As he killed the animal, the slaughterman recited in Arabic a prayer which translates roughly as “God is great and he provides for his children.” His voice was deep and rich and resonated throughout the room, and all the other workers paused and attended to his words. The prayer surprised me, so much so that for a moment I forgot what was taking place in front of me, and I stared somewhat transfixed at the slaughterman instead of the sheep dying in his arms. The prayer and the sincerity of the men transformed a simple, ugly slaughter into a religious sacrifice. Of course, that’s my view on what transpired. I’m sure the sheep interpret the act differently.<br /><br />The slaughterman sliced the sheep’s neck over a drainage trough that caught the animal’s blood. The animal exsanguinated and died quickly, but for a couple of minutes the sheep’s muscles continued to twitch and exhibit reflexive movement. The slaughtermen kept the animal secure with their arms until it finally settled still. They then completely removed the head and injected air under the skin that ballooned the animal so much that they could use the sides of their knives to play the belly of the animal like a drum. The air allowed them to slice through the skin without cutting open any of the internal organs of the sheep, and once they had removed most of the skin they hung the animal on a hook and continued on with the butchering.<br /><br />The temperatures were in the mid-40s the day I toured the slaughterhouse. I’m glad I went during the winter, as I do not want to imagine the smell and heat of the place during a Kabul summer. The only temperature control for the slaughter rooms seemed to be windows, which were open, partially closed, or completely shut.<br /><br />The clothing of the men working there was soaking wet, with what I will not describe. I never saw showers anywhere in the facility. I hope they are located somewhere we didn’t tour, although I expect the most that might be available for the men is cold water from a hose. Most Afghans have no running water in their homes. Even my interpreters, who make comfortable wages by Afghan standards, typically hire someone to bring water to their houses, and then they heat what they need in a pot on their stoves. The men at the slaughterhouse likely were paid enough to enable them to survive. Nothing more than that. They certainly need bathing and laundry services at the end of their working days, but how they manage that I do not know. Theirs is yet another trade in Afghanistan that I’m glad I won’t ever have to undertake in order to support myself.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-67189748871688737832008-12-30T09:12:00.000-08:002009-01-01T07:09:09.929-08:00Christmas in KabulI had not smelled incense in awhile, so I was delighted when I saw on the makeshift altar at Christmas Eve mass the familiar censer. I hadn’t expected the priest here to travel with such an extensive array of liturgical implements. The sight reminded me of my Catholic grade school days when I served as an acolyte for parish funerals. Not only was I excused from class for the duties, but I got to prepare the hot coals that elicited the thick, fragrant smoke when the presiding priest spooned incense into censer after I brought it to the altar. In fifth grade, I was relieved of these duties when another acolyte and I set a rug ablaze just off the altar in the sacristy as we were a bit overzealous on the number of charcoal disks that we set to burning in the censer, and a few fragments of red hot charcoal fell to the rug. Even after that embarrassing fiasco, I still look forward to a mass with lots of smoke.<br /><br /><br /><br /><div style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none">The first whiff of incense smelled wonderful on Christmas Eve, but then I noticed my throat felt even more irritated than usual, and I was suppressing a cough. Air quality in Kabul is poor at best, especially in the winter. Kabul sits in a valley surrounded by mountains, and when the chill air of winter arrives it restricts all the particulate matter floating over Kabul from moving anywhere. The poor population of Kabul burns anything to keep warm – wood, cardboard, tires, plastic – adding even more particles to the pollution. So the air often looks and smells toxic. We don’t help the situation at my base in the middle of Kabul as we have two barrels in which we openly burn all sensitive documents. What I realized was that the incense smoke at the mass, although it served as something of a comfort scent for me, was exacerbating the reactive airways disease I think I have developed the past few months.</div><br />Luckily for me, the good father presiding set the incense aside soon after the mass began, and I regained my comfort until it came time to kneel on the metal hut’s concrete floor. I really thought we’d just sit in our chairs during the periods of the mass when traditionally you kneel, as normally you aren’t expected to press your knees onto cold concrete. But perhaps it was appropriate that I mortified my flesh (specifically my patellae) in this manner while in Afghanistan, as the Afghan year is 1387, a date in the Christian calendar when such pursuits were more common.<br /><br />The priest at this base is known for his scholarly approach to preaching, and he gave an interesting historical account of the origins of the day December 25 as the date Christians celebrate Christmas. In the first few centuries after the death of Jesus Christ, if Christians celebrated Christmas it typically was during the months of April or May. In fact, the birth of Jesus was not even a universal celebration among early Christians, who usually were too busy avoiding persecution to stage a birthday party. Eventually, though, once the Christians were able to worship somewhere other than a hidden cellar, Church leaders decided that the birth of Jesus should not only be a feast, but a celebration during the darkest time of the year, as Christians believe Jesus brought light to a dim world. There doesn’t seem to be a consensus among scholars as to why the date December 25 became the standard for Christmas, but the day does provide the requirement of being relatively dark (and cold, in many places, including Kabul), and also is a turning point in the season when light begins to fill more of our days. (I’m not sure what scholars have to say about present-day Christians residing in the southern hemisphere, who are able to adjust to Christmastide during their warmer months, just as they can tolerate the winter and summer Olympic games coming to them off-season.)<br /><br /><div style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none"></div><div style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none"></div><br />I thought as the priest spoke that my Christmas was not the darkest period of this year for me. That would have been the Thanksgiving holiday, when I was suffering through an extended layover at Bagram Air Field, the sordid details of which you can review in my two previous blog entry. In contrast to Thanksgiving, Christmas Day in Kabul was a jolly good time. The weather here was beautiful: sunny (with reduced smog) and temperatures in the low 50s Fahrenheit most of the day. The dining hall served the same meal for both lunch and supper, which didn’t bother me at all as it was similar to eating a large early dinner followed by leftovers in the evening, the tradition among my family. And the food was pretty good: freshly sliced roast beef, turkey, ham and all the traditional fixings. The only disappointment was the virgin eggnog.<br /><br />My roommate, Matt, and I have been in the habit of playing horseshoes and smoking cigars every Friday afternoon, as that is our one day off each week. Until Christmas, I was undefeated in the pit, but unfortunately I missed a medal in the horseshoe tournament Matt organized for our office. That didn’t dampen my holiday spirit, however, as the entire base seemed more festive than usual, as is appropriate. Everyone has been enjoying treats and gifts from the innumerable care packages sent by friends and strangers alike. I’ve received everything from an indoor basketball hoops that plays stadium rock (“Na-na, na-na-na-na, Hey!”) to Asian shrimp crackers (a favorite of mine).<br /><br />The Army also brought onto the base for the day two horses and two camels. A few people rode the camels, but most of us just took photographs with them and their Afghan handlers (one of whom was a boy no more than ten years old), or at most briefly sat atop one of them. A trip to Qatar and a local camel market there earlier this year taught me that camels are loud, smelly and obstreperous animals. The camels’ Christmas day appearance at my base confirmed that lesson. Those beasts do NOT like people sitting on them. They don’t even like people coming near them, it seems, as one camel spit at a friend of mine when she got close to it. Later in the day, at the horseshoe pit, after she told me that she was glad none of the spittle landed in her hair, I inspected her head and had to tell her that she was carrying around a few crusty streaks of dried camel saliva in her otherwise lustrous hair.<br /><br /><div style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none"></div><div style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none"></div><div style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none"></div><div style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none"> </div><div style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none">I avoided the horses, as I don’t know how to ride them and feared being thrown into the side of a metal Conex box should I attempt to navigate one of those animals through the base. I don’t think the United States military awards the Purple Heart medal for equine-induced traumatic brain injury sustained during leisure time in a war zone, and I envisioned a ride on a horse as producing nothing but pain and embarrassment. I did watch several other more daring folks ride the horses, a few of whom had impressive equestrian skills. However, the animals identified immediately the riders who hadn’t a clue what they were doing atop them, and those riders simply held on as the horses trotted and dashed according to the animals’ whim. One Afghan interpreter had a horse rearing back dangerously on its hind legs, and the smile on the Afghan’s face was really a grin of fear, as the horse appeared to be ready to buck him off the saddle. We notified the physician on duty that he should be ready for some unconscious people coming to him with closed-head injuries, but reportedly everyone walked safely away from their encounters with the animals.</div><div style="BORDER-RIGHT: medium none; BORDER-TOP: medium none; BORDER-LEFT: medium none; BORDER-BOTTOM: medium none"><a style="CLEAR: left; FLOAT: left; MARGIN-BOTTOM: 1em; MARGIN-RIGHT: 1em; cssfloat: left" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkJ-_2RXj9PUKYBSmOcJ59FlQky92AAx58u7x-9BDKlPpOi0cXblbGZHoqdDdzUMkJf4QCiGSTu_Jl8wh4_jbiEp2mYq9BmPQ6OsNL8JpRnTTQgyNR6viVt6WZn7KvfxKiPXr3K0ziM4Q/s1600-h/me+camel+matt+crop.JPG" imageanchor="1"><img style="WIDTH: 316px; HEIGHT: 294px" height="311" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhkJ-_2RXj9PUKYBSmOcJ59FlQky92AAx58u7x-9BDKlPpOi0cXblbGZHoqdDdzUMkJf4QCiGSTu_Jl8wh4_jbiEp2mYq9BmPQ6OsNL8JpRnTTQgyNR6viVt6WZn7KvfxKiPXr3K0ziM4Q/s320/me+camel+matt+crop.JPG" width="324" border="0" vi="true" /></a></div><p></p><p></p><p> </p><p> </p>When I told my niece Isabelle about the camels here for Christmas, she astutely noted that they would be more appropriate on Epiphany, the Christian celebration of the wise men arriving in Jerusalem on camels. She's correct, of course. In fact, I don't think camels are mentioned in the story of the Nativity until the wise men rolled into the Holy Land; but when I inquired at the command headquarters I was told that Tuesday, January 6, the Feast of the Epiphany, would be a normal working day.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-67956796621781009772008-11-30T04:03:00.000-08:002008-11-30T04:09:24.234-08:00A Holiday to Forget: Part II<em>See previous blog entry for Part I</em><br />
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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.<br />
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The movies often show soldiers in similar situations playing cards and throwing dice, the financial <em>fin de siècle</em> 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.<br />
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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. <br />
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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. <br />
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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.<br />
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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.<br />
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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. <br />
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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.<br />
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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.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com6tag:blogger.com,1999:blog-288948379394923861.post-76353426185242742902008-11-29T06:03:00.000-08:002008-11-29T06:05:00.712-08:00A Holiday to Forget: Part II 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.<br />
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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. <br />
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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. <br />
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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.<br />
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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.) <br />
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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.<br />
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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.<br />
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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?”<br />
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<em>Part Two of a "Holiday to Forget" coming very soon (like tomorrow).</em>Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com1tag:blogger.com,1999:blog-288948379394923861.post-45385340211985138472008-11-12T07:39:00.000-08:002008-11-12T07:42:21.894-08:00Problems with ProcurementMany 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.)<br /><br />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.<br /><br />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.<br /><br />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 <em>Goodfellas</em>. So you should assume a rather high percentage of cargo loss if you send out a convoy of supplies to traverse Afghanistan.<br /><br />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.<br /><br /><strong>The Recurrent Problem with Local Vendors</strong><br /><br />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.<br /><br />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.<br /><br />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.”<br /><br />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.<br /><br />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.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com1tag:blogger.com,1999:blog-288948379394923861.post-65314944160204992642008-10-31T03:22:00.000-07:002008-10-31T03:25:11.021-07:00Critically Ill: Afghanistan's Healthcare System (Part Three)<em>This is the third and final article illustrating several of the challenges encountered in building a functioning healthcare system in Afghanistan.</em><br />
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<strong>Hopefully your village has a medical clinic, and hopefully the clinic is more than just a white building</strong><br />
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When you visit a medical clinic in the United States, you direct yourself to a building in which various medical services are provided. In Afghanistan, the local medical clinic might be a physical structure devoted to healthcare, but within its walls very few services are likely provided. Your local “clinic” might even be the home of the government-appointed healthcare agent for your village. Your clinic might have a physician on duty, but most times you will only see there a poorly trained nurse or, even more likely, a local citizen with very minimal medical education who nonetheless is contracted by the Ministry of Public Health to provide the little healthcare he or she is able to offer the community. <br />
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I’m not implying the services always are poor, but they are certainly scarce. In fact, the Basic Package of Health Services for Afghans promoted by the Ministry of Public Health calls for little more than comprehensive vaccinations, pre- and post-natal care, treatment and control of malaria and tuberculosis, and nutritional supplementation. The ministry has not yet been able to provide for the entire population even this rudimentary package as resources – both human and financial – are lacking. The providers available often are not well-educated or trained, but they are committed. When you look at the scant stock of pharmaceuticals, vaccines and essential supplies available to these workers, you realize that even a US-trained physician would have trouble addressing the medical needs of the Afghan communities.<br />
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The construction of a proper clinic building is a source of great pride and hope for Afghan communities. It serves both practical and symbolic purposes. Practically, a clinic building serves as node where community medical treatment can be consolidated and then enhanced. In many remote places, providers dispense government-funded medical care in their personal residences as no dedicated local clinic structure exists. A clinic building also symbolizes that a community not only possesses cache and prestige, but that improved medical services might soon be available. The building itself therefore becomes a sign of hope, prosperity and advancement.<br />
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You must be cautious when constructing medical clinics (in addition to other government facilities such as schools and police stations) in Afghanistan as well-meaning donors and development personnel often have made the mistake of raising a building only to learn that the Afghan government lacks the resources to staff, equip and administer the facility. Then, your medical clinic becomes simply an empty white building with a red crescent painted on its wall.<br />
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<strong>How much is that pacemaker in the window?</strong><br />
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Consider this scenario: You are a patient in an Afghan hospital, and your physician presents you with a prescription for an intravenous pharmaceutical he feels necessary for you to recover from your illness. He doesn’t write an order for the drug to be given by the nursing staff, because the hospital pharmacy doesn’t have the drug in stock. In fact, he probably doesn’t even give the prescription to you, as you are ill and bed-ridden. He probably gives the prescription to a relative of yours in the hospital with you who is there to attend to your needs such as food, laundry and bathing, as the hospital provides none of those services. <br />
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If the relative is able to afford the pharmaceutical, he or she proceeds to a local bazaar where a wide array of drugs can be bought with or without a prescription, even though the quality of the drugs is often suspect, especially those manufactured in Pakistan, China and India. (Afghanistan has made considerable advances in medical care the past several years, but the country is still far from developing a drug enforcement agency.) Medical devices are usually available at these markets as well. <br />
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The situation in Afghanistan is similar to that of many developing countries. The American surgeon Atul Gawande writes of the shortage of medical supplies in public Indian hospitals that has created such a demand for the goods that the hospitals are now surrounded by “rows of ramshackle stands with vendors selling everything from medications to pacemakers.” * In Kenya, I witnessed family members returning from local pharmacies with morphine, hypodermic needles and an assortment of IV fluids.<br />
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If you or your family cannot afford the required drug or device, you simply hope for the best. In these cases, the hospital wards merely serve as holding facilities or inhospitable hospice rooms.<br />
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Because Afghan physicians make very little money working in public hospitals, they do not always give their patients in those facilities proper attention. In fact, sometimes patients languish in those hospitals with no physician care whatsoever. Recently a colleague recounted for me how he found a surgical patient, recently transferred from another hospital with drainage tubes still protruding from his abdomen, wandering the halls of a Kabul hospital with his medications in hand, looking for someone to care for him. The patient claimed he had been in the hospital three days since his transfer, but had not yet spoken to anyone – physician, nurse or technician – on the medical staff. <br />
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Until some sort of plan for proper hospital services is drafted and funded, most of the Afghan medical centers will offer very little to the population. And until then, most hospitalized Afghans will, unfortunately, be wondering the same thing as much of the ambulatory patient population: “Is there any treatment available for me?” <br />
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*Atul Gawande, <em>Better: A Surgeon’s Notes on Performance</em>, p. 241.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-75716382412017961202008-10-23T23:36:00.000-07:002008-10-23T23:38:17.008-07:00Critically Ill: Afghanistan's Healthcare System (Part Two)<em>This is the second article illustrating the challenges encountered in building a functioning Afghan healthcare system.</em><br />
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<strong>There is No <em>System</em> Here: The Example of Medical Waste Disposal</strong><br />
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A few months ago my office began getting regular emails from American engineering teams scattered around Afghanistan who were alarmed that they were encountering medical waste improperly disposed in fields, ditches and trash dumps. The emails included photographs of used syringes and hypodermic needles, empty IV bags and soiled gauze sheets strewn on open ground. The engineers were shocked, and the subtext of their messages was “What are you medical folks going to do about this?” The answer, which for diplomatic purposes wasn’t included so bluntly in our replies, was “We aren’t going to do anything about it right now.”<br />
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Just as Afghanistan has no sound system for providing medical care, it has no infrastructure or service for disposing of medical waste. If you practice medicine in the United States, you take for granted that red plastic boxes designed for safe needle disposal are available in the clinic, and that when they are halfway filled they will be carted, along with larger red bags of other assorted medical waste, to a container where they will wait until the medical waste disposal truck comes to collect the garbage. Later, in places that I hope I never see, community-sized piles of medical will wait for incineration, with non-burning waste subsequently carted away for another type of disposal such as burial in land or disposal at sea.<br />
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The only concern I have with this system is the behavior of mob-infiltrated waste disposal companies that often cut corners, and thus increase profit, in their treatment of the waste, as evidenced on the New Jersey shoreline in the 80s when used needles, dumped from a trash freighter not yet far enough out to sea, washed ashore.<br />
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Afghanistan has no system yet to dispose of human waste, let alone medical waste. Kabul, the largest and most metropolitan of Afghan cities, has no public sewer system. The minority of the homes that have plumbing rely on trucks to empty their individual septic tanks, and the waste is then spread onto nearby fields, one of which is located just a few minutes drive from the center of the city. Outhouses are the most common lavatory in Kabul.<br />
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If an Afghan medical clinic has proper needle disposal containers and designated medical waste garbage bags, an unlikely proposition, then the personnel have no avenue to properly dispose of those receptacles once they are full. The Afghans have two choices: Let the waste sit in the clinic, or heave it onto the closest patch of barren earth or into the nearest open ditch. <br />
<br />
At a few of the major Kabul clinics and hospitals, American development personnel have installed incinerators to ensure more hygienic medical waste disposal. The incinerators have solved some waste problems for hospitals, such as the question of how to dispose of flesh surgically removed from patients. Before, at a major Kabul medical center, amputated limbs and other choice bits of the human body that were not going home with the patients simply were buried on the hospital grounds. The only challenge was to inter the pieces deep enough so that local dogs couldn’t smell and unearth them. <br />
<br />
But the incinerators brought new problems as well. Electricity often is unreliable in Kabul, and the incinerators don’t burn much without power. The incinerators are imported, rather exotic machines here. If one malfunctions, you cannot simply thumb through the Kabul Yellow Pages and pick the medical equipment repair specialist of your choice. The companies who sell the incinerators and other medical equipment typically have, at most, only a few service representatives for the entire country; and Afghanistan is about the size of Texas, with a transporation infrastructure that rivals that within countries such Mali and Papua New Guinea.<br />
<br />
The hierarchical, bureacratic nature of Afghan medical facilities has also worked to subvert the use of what incinerators are in place. In one hospital, a specific employee is charged with collecting the building’s waste and the depositing it in a storage room. However, that employee does not possess the key to the storage room. The key to the storage room door is the possession of another hospital employee, who must coordinate with the waste collection agent to ensure that needle boxes and red garbage bags can pass through an open disposal room door to await incineration. The employee responsible for transporting the waste from the storage room to the incinerator, another actor in this tableau, also depends on the availability and good will of the waste disposal room keymaster so that the waste can transit from the hospital building to the incinerator itself. Thankfully, the door to the incinerator has no lock, so the transportation agent, if motivated, can deposit waste directly into the unit. However, the transportation agent has not trained to actually fire up the incinerator. The process of burning medical waste is the responsibility of another employee, qualified and facile in incinerator operation. Of course, the incinerator mechanic is helpless unless the machine has electrical power, which comes from a nearby outlet through an extension cord. The keeper of the extension cord is yet another hospital employee, hopefully collegial with the incinerator mechanic and willing to produce the cord so that the medical waste can burn. <br />
<br />
Even if medical waste is burned properly in the incinerators, the Afghans have nowhere to dispose of the (hopefully sterilized) metal needles and ash. I don’t know where they deposit this stuff. My guess is that it somehow makes its way to field or ditch where American engineers, aghast at the sight of it, avidly photograph the scene and rush the images to us medical personnel. I contend that improperly disposed waste is an encouraging symbol as it represents the fact that Afghans somewhere were actually receiving some sort of medical care. I’m more concerned that most Afghan medical clinics still lack the supplies to even generate medical garbage.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-3909444768378310382008-10-15T09:22:00.000-07:002008-10-15T09:32:44.622-07:00Critically Ill: Afghanistan's Healthcare System (Part One)Most medical professionals, when they first arrive in Afghanistan, are pretty shocked when they recognize the poor quality of medical care available in this country. The average Afghan probably has little to no access to healthcare at all, but what is available publically might be less than what an American can supply at home from the family medicine cabinet. Decades of war, corruption, destructive cultural biases and international indifference have devastated Afghan society, including the education system and national medical institutions. The healthcare system in Afghanistan today, where the government’s per capita expenditure is less than $3, is a dissheveled, ailing patient on its back and in need of resuscitation. I’m not able to dissect the entire system, examine its components, and then propose a plan to improve its functioning; but I can produce several vignettes which I hope illustrate the problems. Consider it a short primer, in two parts, on the state of Afghan healthcare today. <br />
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<br />
<strong>“Physician” is More a Title Than an Academic Degree</strong><br />
<br />
Until very recently, you didn’t have to do much to graduate from medical school in Afghanistan. Admission standards were extrememly lax, with several hundred students matriculating each year to the most prestigious medical school, Kabul Medical University (KMU). Once enrolled as a student at KMU, you didn’t have to attend class to graduate. Attention to the seven-year medical school curriculum was optional: No student failed, and students did not know the nuisance of medical competency and licensing exams. At the end of the seven year program, which essentially was a protracted lecture series, all students graduated with an M.D. degree and simply chose what field of medicine best suited them. Although some students entered residency programs at Afghan hospitals, such advanced training certainly was not required. You want to be a surgeon? Go ahead and cut. You’re a medical doctor. <br />
<br />
Many US medical school mercifully utilize the pass-fail grading system, but students must then pass a series of national licensing exams before continuing on to further medical training and autonomous practice. The Afghan system was, unfortunately, pass-pass. <br />
<br />
The system is slowly changing. Selection for a seat in a medical school class is now much more competitive, a fact that angers many influential Afghans who have grown accustomed to easily “enrolling” their kin in medical school. Tuition at the schools is free, so wealthy and connected Afghans often considered the academic excursion as nothing more than a seven-year shopping sojourn for their children. Additional rigor has evolved as at the end of the medical school curriculum as well, as graduating students must pass an exam in either medicine or surgery in order to practice.<br />
<br />
These changes in medical education should produce more competent physicians in the years to come, but unfortunately the quality of physicians already practicing in Afghanstan varies tremendously. Many physicians possess an understanding of human biology not quite as extensive as that of a bright American high school student. Some physicians who have received advanced training in medicine or surgery nevertheless still lack a basic understanding of the fundamentals of medical intervention. An American orthopedic surgeon here recently considered it a victory that he persuaded the Afghan surgeons to stop sharing one set of operative instruments for the two surgical cases taking place in the same operating room. <br />
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Afghanistan does boast some very good and talented physicans and surgeons. Often these people have trained in the former Soviet Union, Pakistan or Turkey. Others are simply very dedicated, intelligent, and driven to provide the best possible care under the circumstances. Unfortunately, there are too few of these folks around, and it will be years before medical education reforms and training initiatives serve to stock the Afghan healthcare system with a preponderance of competent physicians. <br />
<br />
<strong>If You Paid Me Like an Interpreter, I Would Practice as a Doctor</strong><br />
<br />
The monthly salary for a physician working at a public hospital for the Ministry of Public Health is about $50. Physicians working for the Afghan Army earn more, but still only $200-300 per month. An Afghan interpreter working in Afghanistan for the United States, another government, a foreign business, or one of the numerous non-governmental organizations (NGOs) here averages $600-800 as a monthly salary. Medical students in Afghanistan, as a population, have much better facility in English than most other groups of people. The quality medical texts available here are often written only in English, and the medical school curriculum (that is a seven-year program modeled on the British system) includes English language instruction. Therefore, a shocking number of medical school graduates in Afghanistan have no intention of using their degress to provide medical care to their countrymen. Instead, they graduate from medical school and immediately find employment as interpreters.<br />
<br />
Many physicians who do work at the public and military hospitals are strictly morning employees. They cannot afford to support their families on their government salaries, so they practice at the government institution until about 13:00, then they depart to their private clinics where they attend to patients who are able to pay cash for their services. Some brazen physicians even utilize the government clinic buildings and equipment to conduct private clinics. Security at the military hospitals is often compromised as some physicians instruct their private patients to see them at the military installation, even though entry to those facilities is supposed to be restricted. At another government hospital, an advising American intensivist was shocked to find the Afghan ICU attending physician absent from the critical care ward every afternoon, but using internationally donated equipment and supplies on the ground floor of the hospital to conduct his profitable private practice.<br />
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The consequence of the pitiful salaries and short working hours of Afghan physicians charged to provide medical care to the overwhelming majority of Afghans is that the wealthy have the opportunity to pay for decent care, while the poor often have trouble even finding a physician they can afford to visit. The physicians themselves are stuck in a system that offers no financial security if you treat the needy. Moreover, many Afghan physicians who might look forward to a relatively lucrative private medical practice simply look to emigrate from Afghanistan. I know personally several well-trained doctors who chose to forfeit any opportunity to practice medicine as they secured visas and moved to the United States, where they will be lucky to live a middle-class existence after their arrival. No institution in the US will recognize their Afghan medical credentials, and they will more likely be driving a taxi cab than ever seeing clinic patients in any capacity. Their country misses them.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com1tag:blogger.com,1999:blog-288948379394923861.post-745936416659124652008-09-21T08:45:00.000-07:002008-09-21T08:52:53.895-07:00COIN for the Realm: Novel Approaches to Counter-Insurgency Operations in Afghanistan (Part Two)(<em>This is the second article in a two-part series</em>. <em>See the previous post for part one</em>.)<br />
<br />
<strong>Operation Frigid Air</strong><br />
<br />
The warm weather months in Afghanistan long have been considered the prime fighting season. In winter, it’s just too cold to fight. Key roads and passes also become too difficult to travel with all the snow and ice. But I also believe that the considerable heat of the oppressive Afghan summer months brews irritability and anger in the breasts of many Afghans, who must leave their homes that have been transformed into literal mud-brick ovens by the summer sun. It is no coincidence to me that southern Afghanistan, the traditional home to the Pashtuns who comprise the majority of the Taliban, is also the hottest region of the country. Unable to stand the heat of their homes, many Pashtun men must loiter out-of-doors enveloped in a surly, violent funk, which makes them easy recruits for the Taliban who can promise immediate relief with a cooling, windy ride in the bed of a white Toyota pick-up truck. After a brief respite from the heat, the new recruits are more likely to take up with the Taliban and look for women to whip, books to burn, and children to chastise for such unGodly activities such as kite flying and marble shooting.<br />
<br />
I theorize that an air conditioner in the home of every Afghan would keep most males inside during the summer fighting season, and render impotent the aforementioned Taliban recruiting strategy. At my base in Kabul, we make great use of the Chigo brand of air conditioner, manufactured in China and readily available in Afghanistan. Many Afghans have an aversion to Chinese goods, which the natives here think inferior even to Pakistani products. But I don’t think any Afghan would reject a free air conditioner, no matter what the brand.<br />
<br />
The cost to install in every Afghan home a Chigo air conditioner would be substantial. At a unit price of $300 and an estimated five million homes to cool, Operation Frigid Air would generate a bill of $1.5 billion. Consider, though, that the US already has spent $172 billion in Afghanistan since 2001. At less than $2 billion, we could pacify a country for less than it costs to rescue a major US bank. Consistent, clean electricity for all the units would be problematic, but with potential Talibani indoors luxuriating in their pleasant 70⁰ F environs, the countryside and cities would be quiet. Development teams would then have the opportunity to build the utility infrastructure the country lacks, without the danger of insurgents destroying power lines and applying dynamite to hydroelectric projects. <br />
<br />
<strong>Perpetual Star Strategy</strong><br />
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One of the most popular television shows in Afghanistan is <em>Afghan Star</em>, a glorified talent show modeled on <em>American Idol</em>. The founder of Tolo TV, which produces <em>Afghan Star</em>, estimates that 11 million Afghans, or nearly one-third of the population, are avid viewers. You have to be a little suspicious of a viewing audience estimate from a television producer who surely will overestimate his production’s popularity, much like a D.C. protest march organizer’s participant estimate will usually quadruple the National Park Service’s figure. But I work with Afghans, and I will testify that they were all talking about the final episode of <em>Afghan Star</em> in March. One interpreter told me that it not only was his grandmother’s favorite television show, but the only program she watched. <br />
<br />
The United States should assist in producing a continuous run of <em>Afghan Star</em>, perhaps even creating regional shows in the native languages that send their winners to a national competition. Afghans and Americans are alike in many ways, but especially similar in our avidity for televised camp. Entire villages gathered on common ground to watch the final episode of <em>Afghan Star</em> on the single small television available in their locale. The Afghans who did not watch the last season of <em>Afghan Star</em> likely missed the show only because they had no access to a television. Several thousand large-screen television sets distributed throughout the country and a perpetual dose of <em>Afghan Star</em> would leave the vast majority of the country too mesmerized by the national singing talent to ponder subversive activity. The interest in <em>Afghan Star</em> is so intense here that any noise or disturbance promulgated by the Taliban during an episode would draw swift vigilante justice by offended locals who would then scurry back to catch the remainder of the televised entertainment. <br />
<br />
<strong>A Professional Approach to Finding Osama bin Laden</strong><br />
<br />
Although recent reports claim that he does not control the day-to-day operations of Al Qaeda any longer, and efforts to locate and capture him are not truly counter-insurgency operations, Osama bin Laden remains a fugitive that many Americans would like captured. Military experts and diplomats argue that the forbidding, tribally controlled terrain of northwest Pakistan, where bin Laden most likely hides, foils attempts to locate him. However, the difficulty in determining bin Laden’s whereabouts does not stem from the mountainous, rugged geography that engulfs him, but from the fact that the United States has not utilized available experts to pinpoint his whereabouts.<br />
<br />
bin Laden’s full name, estimated wealth and last known location should be forwarded to an aggressive university development office with the additional misinformation that Osama is an alumnus known to distribute his wealth liberally to initiatives dear to him. If the Cornell University alumni donation experts were given the incentive to track down bin Laden, they would likely have a viable address for him in 2-3 weeks. I have attended three major universities, and I cannot shake free from any of them no matter how often I move. Sometimes I think that the schools each surreptitiously placed a LoJack beacon somewhere under my skin before I left the institution. The US military and our intelligence agencies are capable of amazing feats; but to find Osama, they should move over and let university development personnel, the true bloodhounds when it comes to this sort of work, take over the mission.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com3tag:blogger.com,1999:blog-288948379394923861.post-53161598597797705982008-09-19T08:35:00.000-07:002008-09-19T09:01:13.969-07:00COIN for the Realm: Novel Approaches to Counter-Insurgency Operations in Afghanistan (Part One)<div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div class="separator" style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhom3oRvUhvns9g6tiaXUUnBBAu26DFafgbNl_RR7uabe1vAyuMdxxz89qzidel8DMiIjWEL9JGTHEEHDisi60ycT6cFo0AM6e2hWDO-BY4O6EVtKh8iYupTW3RVbJAXlXAN0ghw6pYwlA/s1600-h/coin+photo+1.JPG" style="clear: left; cssfloat: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5247758705214489970" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhom3oRvUhvns9g6tiaXUUnBBAu26DFafgbNl_RR7uabe1vAyuMdxxz89qzidel8DMiIjWEL9JGTHEEHDisi60ycT6cFo0AM6e2hWDO-BY4O6EVtKh8iYupTW3RVbJAXlXAN0ghw6pYwlA/s200/coin+photo+1.JPG" style="float: left; margin: 0px 10px 10px 0px;" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh9r2xsS1hH6gWFOehRX840ts8bZmBWaCbWi0x7FhI9gNNB7Wt6ZBuyQgnIBXuHGUxr25iB0TTtBw5lEJxj0H2K5ju8oZ-HwXhQ1aYFK1Byp_s617X5bDTe9DQaseFiXgB4y_tkCpNsMas/s1600-h/coin+photo+2.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img ad="true" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgNaD2R3P5suwZ2n9T4jX5K2Ci-l8vQdVrY5XzScJhR_RtkVMA2Pl800HHWjwjk14mKXn6aydBvFBSrG5o9XuHz4MOykxvH3arWJQGFv4y9lJZ7dA3XbtI5hzm_kGOH0yULe0mCrQhs4-M/s200-r/coin+photo+2.JPG" /></a></div><br />
<div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"><strong>Photographs</strong>: I asked none of these Afghans to pose for snapshots. I simply found them stationary and waiting for me to photograph them when they saw I had a camera.</div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"><br />
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In his latest book on the Bush administration, Bob Woodward attributes much of the reduction in violence in Iraq to a new military and intelligence strategy that has proven as revolutionary as it is effective. Somehow, and Woodward gives no details on exactly how, the United States has developed a widely successful approach to locating and eliminating insurgents in Iraq. Information on the actual techniques currently is classified information. I’m not sure if the military plans to incorporate similar operations in Afghanistan. I can offer, however, a few novel techniques that policy and strategy experts in D.C. might not have considered. These suggestions are in no way classified, but I believe them to be imminently applicable to the conflict in Afghanistan, so I encourage and welcome their incorporation into any other operations the United States military might be planning for securing peace in Afghanistan.</div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"><br />
<b>The Polaroid Lure</b><br />
<b><br />
</b>The strength of this technique is rooted in a simple cultural fact: Every Afghan loves to get his or her photograph taken. I think we have all encountered, both within the United States and elsewhere, people shy toward the camera. Especially in developing countries, many people are loathe to be part of any type of photodocumentation that might be perceived as evidence of their supposed backward, funny ways to curious foreigners. In Vietnam, I saw crippled, kyphotic elderly women stand and run when I raised my camera near them. In Cambodia, I witnessed a man fishing in a river with his bare hands who managed to duck under water and hold his breath for a period of time that would have impressed Houdini, thereby negating my opportunity for a snapshot. But in six months, I have not met a single Afghan unwilling to pose for a photograph.</div><br />
At the Afghan National Military Hospital recently, I was walking the grounds photographing the new fountain and landscaping (all done at the expense of the ICU renovation) when I noticed that many people I was passing had stopped and posed, expecting me to photograph them. A few seemed quite irritated that I didn’t include them in shots of the nearby water and trees. You don’t need to ask explicitly for permission to photograph an Afghan. All you need to do is hold up your camera, and all activity in front of you will stop until you signal that you’ve taken all the photographs you need.<br />
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Military success in Afghanistan depends on the successful implementation of COIN: counter-insurgency strategy. The Polaroid Lure technique is a manifestation of COIN strategy in a most simple and elegant form. Let me reiterate the last sentence from the previous paragraph: <i>All you need to do is hold up your camera, and all activity in front of you will stop until you signal that you’ve taken all the photographs you need</i>. The Taliban are Afghans, mostly, and we’ve all seen pictures of them riding around Afghanistan in their white Toyota pickup trucks looking for women to whip, books to burn, and children to admonish for such unGodly activities such as kite flying and marble shooting. I theorize here that the joy you see in the faces of these Taliban is NOT simply a display of religious zeal and a devotion to a misguided revolution, but the reflexive exuberance of any Afghan to the placement of a functioning camera in front of him.<br />
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Most Afghans are even more than excited, in fact overwhelmed, if you are able to offer them a copy of their photographs. Such a gift creates an immediate and deep bond of friendship and gratitude. Personal photographs are treasured mementos here, and not simply because most Afghans cannot afford cameras. The gift of a photograph is considered a token of hospitality and appreciation, both extremely important values in Afghan culture; and especially in the culture of Pashtuns, who form the predominate ethnic group in Afghanistan and the majority of the Taliban.<br />
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The United States should issue every soldier, sailor, airman and Marine coming to Afghanistan a Polaroid One Step camera and several cases of film, with orders to provide an instant photograph for every Afghan met. Battle reports detail that, in combat, US forces typically encounter Taliban fighters at a distance of 700—1000 meters, close enough that the insurgents would be able to detect cameras in the hands of US military personnel. Let me reiterate the last sentence from the penultimate paragraph: <i>All you need to do is hold up your camera, and all activity in front of you will stop until you signal that you’ve taken all the photographs you need</i>. My theory holds that not only would the Taliban halt any military assault and graciously pose for a photograph, but after the benighted rascals received a personal snapshot of themselves, they would lose any urge to fight and consider us infidels quite good folk after all. The hearts and minds of the 99.99% of the Afghans who want nothing more than an end to conflict here also would be ours.<br />
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The cost of such an operation would be minimal, especially when contrasted with the cost of US military efforts in Afghanistan since 1991, a figure the Congressional Research Service estimates to be $172 billion as of July 2008. Even if the US military ordered at the list price of $75 from Amazon.com enough Polaroid One Step cameras for all NATO and US military personnel in Afghanistan, with an additional order of enough film for one snapshot each of the estimated 35 million Afghans (at approximately $1.50 per sheet of film), the total cost of operation Polaroid Lure would be under $57.5 million. The total cost would be even less with a bulk order from Polaroid if the federal government bucks tradition and decides that a contract price for goods bought in large quantities from manufacturers should be less than what the typical suburban consumer would pay when buying the item singly. Additionally, the bulk Polaroid purchase would finally provide solid evidence that military spending creates the vaunted economic spinoff that Congressional hawks like to tout as rationale for every tax dollar spent on expensive military procurement packages.<br />
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(<i>Next blog post: COIN (Part Two, including Operations Summer Freeze and Afghan Star, and a strategy to find Osama bin Laden</i>.)<br />
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<div class="separator" style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; clear: both; text-align: center;"></div>Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-84130631201793351642008-09-16T08:09:00.000-07:002008-09-16T08:11:48.341-07:00Mazir-e-Sharif: A Trial with Wind, Dirt and a Troublesome ProstateWhoever first pronounced that “forty is the new thirty” likely was not a male suddenly unable, at age forty-one if my case is exemplary, to sleep through the night without waking at least once to urinate. Typically this disrupted sleep is due to a prostate gland that, after four previous decades of relative dormancy, is now blossoming like a desert lily at daybreak; and which delights in tickling a bladder that subsequently demands evacuation no matter what the present volume. I certainly did not have this problem at age thirty. Now, in my early forties, I can rarely escape the nightly interruption, even if I attempt to dehydrate myself before getting supine for slumber. In fact, I could blood let myself to a near death before sleep but still find myself in the bathroom at 02:00.<br />
<br />
I don’t mind the interruption if I am home, or even at my base in Kabul as the toilet is only several yards from my bed, and usually I can take care of business and be back asleep within a few minutes. But during my recent trip to Mazir-e-Sharif in northern Afghanistan, where I slept in quarters without bathroom facilities, I found the nightly physiologic intrusion more burdensome. There, on a US military base that simply is a collection of plywood shacks and large shipping container boxes sitting on packed gravel and fenced by stacked barricades, I awoke each night to the famed Afghan 100 Days of Wind – extended in Mazir-Sharif through the moonlit hours and accompanied by the ample airborne dirt and silt from the surrounding desert. Every night, I awoke and trekked in the dark thirty or so yards to the toilet trailer with my head down as the dirty air stung my eyes; but I did notice one night that young, thin trees planted by the camp’s headquarters, virtually stripped of leaves either by the wind or a local goat, bent at nearly ninety degree angles in the gusts.<br />
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Every night, before I even began another quest for uninterrupted sleep, I took notice of the wind. In fact, the first time I lay in my bunk I thought that an active loading dock sat behind my quarters, as I heard the intermittent percussion of wood and metal colliding. The following morning, I discovered that the sounds were from the corrugated sheet metal, used as roofing on the buildings and shelters surrounding me, lifting in the wind and then crashing together or into the wooden beams that were supposed to hold them firmly in place.<br />
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The dirt raised by the wind permeated everything, even the interior of the buildings themselves. The nearby Afghan military hospital, where I spent two days, had a film of dirt everywhere: on the floors, on the patient’s blankets, on the operating room equipment. The dirt simply overwhelms the new hospital’s air filtering system. I went to inspect the ophthalmology equipment at the facility and instruct the staff, which is devoid of an eye surgeon, on its use. The room marked “Eye Clinic” had been locked for months, and when we opened the door I felt as if I were Howard Carter as he peered through the hole he had drilled into sealed door of Tutankhamen’s tomb, for I saw everything inside the clinic perfectly preserved under a soft, quiet layer of silt.<br />
<br />
The weather in Mazir-e-Sharif remains very warm, and I was grateful for the sultry climate in the middle of the night when I walked to the bathroom in shorts and a t-shirt. I also appreciated the air conditioners that cooled most of the buildings. The recirculated air may have been dirty, with thin clouds of dust visibly emanating from the air conditioners’ vents, but at least the buildings remained a pleasant temperature. I tried to focus on the comforting cool every night as I returned from the bathroom and climbed back into my sleeping bag, comfortable again below the waist but tasting on my tongue the ancient soil that permeates the air in Mazir-e-Sharif.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com2tag:blogger.com,1999:blog-288948379394923861.post-43353716346543804512008-09-09T03:46:00.000-07:002008-09-09T03:50:16.686-07:00Earthquake!I lived in southern California for eight years and learned a few things about protecting myself during an earthquake. I know that you are supposed to take cover under a protective object if a quake begins, or better yet leave a building that is shaking in a temblor. Recent events lead me to conclude that the typical Afghan training for earthquake safety is a bit different, as a few days ago when I felt the floor beneath me suddenly begin to sway, the Afghan military officers who surrounded me made no movement to duck underneath the heavy table in front of us; nor did they break for the door. Instead, they looked at me with effusive smiles, and the officers who spoke English simply said “Earthquake!” with faces full of excitement and anticipation such that I haven’t seen since the last time I was on a rollercoaster with my young nephew Davey Boy.<br />
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The Afghan officers’ response was in keeping with the cultural notion of <i>inshallah</i>, which means God-willing and attests to the Muslim belief here that your individual fate is truly in the hands of God; and marks as foolish any personal attempts to evade the will of God. I’m not sure what the Almighty had planned for me during the earthquake, but I was pretty confident that as soon as the ground began rocking, I received a direct message from God instructing me to promptly get my ass out of the building. But a friendly Afghan colonel next to me put his hand on my shoulder to indicate that I should stay seated; so I was forced to subscribe to <i>inshallah</i> myself for a few minutes. <br />
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I had encountered the concept of <i>inshallah</i> before in another predominately Muslim country: Turkey. Just a few days before I arrived on a visit to an uncle working in the city of Izmir on a highway construction project, a Turkish laborer had fallen into a pool of water that unknowingly was charged with electricity due to a faultily wired pump working to drain the liquid. An American supervisor found the Turk not breathing and with a poor pulse, so he disconnected the pump, pulled the victim from the water and began administering CPR. To the amazement of all the Americans nearby, the Turk responded: He regained consciousness, and was pronounced healthy and fit after an extensive evaluation and short stay at a local hospital. The other Turks, however, were not impressed with the CPR performance or their countryman’s recovery. “<i>Inshallah</i>,” they claimed, indicating that God simply willed the recovery; and why was this American-construction-supervisor-turned-paramedic so proud of himself?<br />
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I never heard a comment from the Turk who survived due to the CPR. Apparently God instructed him to find employment elsewhere, as he never returned to the construction site.<br />
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The building that I felt rock during the quake here is a model of Eastern Bloc architecture and engineering, built in the 70s by the Soviet Union. Once the earthquake began, I remember thinking “This shack is coming down and fast!” but such a reactionary conclusion failed to acknowledge the sturdy Afghan construction found throughout the country. It’s not unusual to encounter remnants of a wall that would still be completely intact had not Genghis Khan’s mob assaulted it with the Mongolian equivalent of a Stinger missile sometime around the year 1250. Many buildings here are the products of masons who were absolute masters of their craft. Even the mud brick homes that look as if they will simply melt away in the near future are quite stout. The medical office building in which I withstood the earthquake had been upright more than thirty years, a testament to its structural integrity as it surely has withstood several earthquakes yet remains standing. In fact, the rule in Afghanistan is that, in the event of an earthquake, it’s much better to be in an older, tested building than a new structure that may not have had its girders rocked before.<br />
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The earthquake announced itself a bit differently from the few I have felt in southern California. I first noticed slow, smooth undulations of the earth. Then a brief pause interceded before the ground shook more violently for 10-15 seconds. After the initial action, I could swear I felt a series of delayed tremors, but then I realized that I was sitting in a rickety chair barely able to hold my girth; and what I thought were after-shocks were actually my own anxiety-induced spasmodic gyrations that had converted my contorting seat into nauseating carnival ride akin to the Spinning Teacup I rode as a kid whenever Drago Amusements came to the Kokomo Mall parking lot.<br />
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News reports gave the earthquake a 5.6 rating on the Richter scale, although it’s difficult to ascertain the magnitude of a quake in Afghanistan as the country has no agency to monitor the events. The epicenter was located approximately 100 miles northeast of Kabul, but thankfully no serious injuries or damage occurred. The earthquake reminded me that the geotectonic plates beneath me continue to move and ram each other, creating not only earthquakes but the grandeur of the nearby Hindu Kush mountains, the Korakoram range in Pakistan, and the remainder of the Himalayas beyond. I’m hoping the plates don’t engage in any more aggressive jostling for position during my remaining time here, <i>inshallah</i>.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com2tag:blogger.com,1999:blog-288948379394923861.post-235515895002646512008-08-30T09:01:00.000-07:002008-08-30T09:06:51.820-07:00An Afghan LunchInterview 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?<br />
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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.<br />
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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 <i>palao</i> and include a combination of raisins, cherries, carrots and meat. The <i>palao</i> 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.<br />
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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.<br />
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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.<br />
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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.<br />
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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.<br />
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The meat at lunch might be served in a small individual dish, cut into slender strips and mixed into the <i>palao</i>, 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.<br />
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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.” <br />
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I asked if it is a certain type of melon, and he responded, “Like a watermelon, but just a MELON.”<br />
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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.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com6tag:blogger.com,1999:blog-288948379394923861.post-69463914460233176542008-08-22T08:58:00.000-07:002008-08-22T09:09:29.002-07:00Taking ChaiLast 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.<br /><br />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.<br /><br />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.<br /><br />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. <br /> <br />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.<br /><br />“You mean the chai boy?” my uncle responded.<br /><br />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?”<br /><br />My uncle looked at me as if I had just questioned the precepts of Euclidian geometry. “Ron,” he said, “That guy is the <i>chai boy</i>. That’s his job. To serve chai.”<br /><br />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.<br /><br />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. <br /> <br />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.”<br /><br />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.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-48273183355896907562008-08-16T09:04:00.000-07:002008-08-17T08:59:29.740-07:00Sitting for a Kuchi Tribal CouncilThe 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.”<br />
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<div class="separator" style="clear: both; text-align: center;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;">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.<br />
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</div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxNcyHN20Ljp_trwXOY3_kcYy4CHt_6VY_Nu5bAeTkmjM-DxQNWOo3s5QLCG62GPjaULg7jhqk8YlhE32gNXZCDI9wbrcxTu9xwJbsoyQEe4Hc_xlitRwh5bo1LrQ_GpTYwhBPOW_xN3E/s1600-h/aid+truck+assault.JPG" imageanchor="1" style="clear: left; cssfloat: left; float: left; height: 224px; margin-bottom: 1em; margin-right: 1em; width: 321px;"><img border="0" fd="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpH64UPsjfjDvo1ADanlj8PC-yifjoEC7Atj3qYp81N9bKC79BHdE-bl7la9ar8qTU2mgmBryOB7u83lTAhsHf44Ii8fkc8o4xzRgwss0CHqkNknanrtnt0gtEgsdvMJp9nKmOpKmChyg/s320-r/aid+truck+assault.JPG" /></a>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.</div><br />
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.<br />
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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.<br />
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<div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;">The entirely male Kuchi delegation that awaited us at the settlement included the group’s representative in the Afghan parliament, its <em>mullah</em>, 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 <em>mullah </em>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.</div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_MPuhr5ZwjMzUCiiv5wKeMvZY7qpuQU-S1cvKZpjcMpv2OsmnUVPoO7czx3GxB3N173zx_XcjcYlihTtExqf00TXr-VPiZIRF5QJP11f93iFkMovV_srnfl_cKZwohd1gAIMEpgSLnvA/s1600-h/in+the+elders+march.JPG" imageanchor="1" style="clear: right; cssfloat: right; float: right; height: 219px; margin-bottom: 1em; margin-left: 1em; width: 321px;"><img border="0" fd="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjf2y12w4Tle6Us2wg7zVYemWtMnscIwTbmDg9KLfC3Bei3I1kRAVuOnDqr8LaxCTS83KeWGrUm3Vt1OPvLIpJqhvk5Gx3qJnjvDME4JVBsSKPWMmtsKUddhXxM8rmu6hewxYKW9t1W_7I/s320-r/in+the+elders+march.JPG" /></a>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.</div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"></div><div style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none;"><br />
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 <em>muezzin</em> across from me began chanting select verses of the Koran that nobody but the <em>mullah</em> 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!”</div><br />
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.<br />
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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 <em>mullah</em> 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.<br />
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<div class="separator" style="border-bottom: medium none; border-left: medium none; border-right: medium none; border-top: medium none; clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9xS2S9VXowKaaeIjN-oT_z98Vv6QeYb2k0r73NPkCRalP6HZwYbPYzmn-B9YyZMbdoGqJOmJjC0AzhhgzEx72V82AWv_qXhGG3z-VwQN3eW-6Lt1ZhC_P4W3yZixgp4iGnCIixRBJNx4/s1600-h/pepsi+leader+1.JPG" imageanchor="1" style="clear: right; cssfloat: right; float: right; height: 282px; margin-bottom: 1em; margin-left: 1em; width: 273px;"><img border="0" fd="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnrx0XYRj5d9kSSYD_tBs0utgAkhwz7Tef5V0Uy3PI1i9wmTbFnAepgdudhdR8xCuD1_jC58Su4mgOb6UtXiPSyfwKXNtIJ9IirhFNdZFyzTJAKPZPTDm2iE5V9KuSE_o-K3lZzTEHYRM/s320-r/pepsi+leader+1.JPG" /></a></div>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.”<br />
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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 <em>muezzin</em> 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.<br />
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<em>Below is a short slide show with more photographs from the event.<br />
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<br />
<embed type="application/x-shockwave-flash" src="http://picasaweb.google.com/s/c/bin/slideshow.swf" width="400" height="267" flashvars="host=picasaweb.google.com&captions=1&noautoplay=1&RGB=0x000000&feed=http%3A%2F%2Fpicasaweb.google.com%2Fdata%2Ffeed%2Fapi%2Fuser%2Fronaldwilly500%2Falbumid%2F5235471324166090753%3Fkind%3Dphoto%26alt%3Drss" pluginspage="http://www.macromedia.com/go/getflashplayer"></embed>Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-53832735014109762202008-08-08T10:50:00.000-07:002008-08-08T10:56:32.732-07:00The European Face of Afghanistan<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhp4siS8BE45pogkIFFzuvSbS7kgrnpok-4S8k255SL2PQnELnH35GgqMLy8YXb3uDXCTihUmwTaN1qNWS1HENyhgzVGxReNNhYR9cnJCw1kpbdj2ttp3JBFqXFGNwlThmJaX90EU2SjjY/s1600-h/samsheen.JPG"><img id="BLOGGER_PHOTO_ID_5232206577399579090" style="FLOAT: left; MARGIN: 0px 10px 10px 0px; CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhp4siS8BE45pogkIFFzuvSbS7kgrnpok-4S8k255SL2PQnELnH35GgqMLy8YXb3uDXCTihUmwTaN1qNWS1HENyhgzVGxReNNhYR9cnJCw1kpbdj2ttp3JBFqXFGNwlThmJaX90EU2SjjY/s320/samsheen.JPG" border="0" /></a><br /><br /><br />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.”<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com2tag:blogger.com,1999:blog-288948379394923861.post-87515136486084133532008-08-03T20:50:00.000-07:002008-08-03T20:55:51.974-07:00Afghan Army Physician Recruitment Strategy: A War with PakistanThe 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.<br /><br />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.)<br /><br />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.<br /><br />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 <em>mujahedeen </em>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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com3tag:blogger.com,1999:blog-288948379394923861.post-44457312755657618442008-07-26T08:26:00.000-07:002008-07-26T08:42:56.389-07:00Kandahar Police: Prosthetic limbs and eye makeup<em></em><br /><br /><em>Photograph</em>: Policemen and police recruits display<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfUDx_pTq-1XuKDTxa8M8rJ4gSq1KWaV-SEGy5JHaIV-spJOaTWOxdGOs5rDHELbrAOXKWXCz59mjciq_exPhB8NOAGcKD_kUNug2_0M9EiamL6cDSLUper3qqiMQ9DAN-sqsWTFK7eRg/s1600-h/anp+recruits+group+side+shot.JPG"><img id="BLOGGER_PHOTO_ID_5227346223748810562" style="FLOAT: right; MARGIN: 0px 0px 10px 10px; CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfUDx_pTq-1XuKDTxa8M8rJ4gSq1KWaV-SEGy5JHaIV-spJOaTWOxdGOs5rDHELbrAOXKWXCz59mjciq_exPhB8NOAGcKD_kUNug2_0M9EiamL6cDSLUper3qqiMQ9DAN-sqsWTFK7eRg/s320/anp+recruits+group+side+shot.JPG" border="0" /></a><br />a short-lived semblance of order and discipline.<br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br />My recent trip to Kandahar in southern Afghanistan was to serve as the medical monitor for an Afghan police recruitment and training initiative. A few hundred policemen and new police recruits arrived at a training center where they would first be administratively processed into the Afghan police force (if necessary), medically cleared for service (no double-amputees or opium addicts, please), then trained by teams of Americans and Afghans on proper policing. Some of the men already had served on the Afghan police force for a year or longer but had never undergone basic police training: Upon joining the force, they simply received a uniform, a weapon, and a duty post. Several of these gentlemen displayed for me wounds already sustained in battles with the Taliban, and a dozen or so took my hand and rubbed my fingers over palpable <span class="blsp-spelling-error" id="SPELLING_ERROR_0">schrapnel</span> lodged in their legs, arms and scalps.<br /><br />The medical evaluation included a urine screening for drug use, a brief medical history and a cursory physical exam. Hash and marijuana use are so prevalent in Afghanistan, especially in Kandahar where tons of marijuana are grown, that a positive test for THC (the active ingredient in pot and hash) does not disqualify one for police service. In fact, if recent hash or marijuana use did disqualify recruits, it would be impossible to field a <span class="blsp-spelling-error" id="SPELLING_ERROR_1">sizeable</span> police force as typically up to half of the new police officers test positive for THC. Opium use is a different story. Desperate as the police force may be for new members, an opium addict is not likely to respond well to a regimented and physically demanding police training camp.<br /><br />Most of the policemen and recruits were young and healthy, and easily passed the physical examination. I had to fail a few who I thought might kill themselves while running and marching and otherwise exerting themselves physically during the upcoming training. The failures included a gentlemen taking the blood anti-coagulant C<span class="blsp-spelling-error" id="SPELLING_ERROR_2">oumadin</span> after heart valve replacement, and another current policemen in atrial fibrillation medicated with <span class="blsp-spelling-error" id="SPELLING_ERROR_3">digoxin</span>. (His bottle of pills had a label with “Poison” written in bold letters under the name of the medication.) A surprising pass was a middle-aged officer with a left lower leg amputation who was determined to remain on the police force and who, at my request, could easily hop on his nicely constructed prosthetic limb. At least two of the policemen had lost a single eye in previous trauma (including one who claimed he was shot by an American soldier), but I passed them as they assured me they could shoot using their remaining good eyes.<br /><br />My biggest problem with the screening was not determining what medical problems and physical complaints where problematic for police service, but maintaining order among the free-ranging <span class="blsp-spelling-error" id="SPELLING_ERROR_4">Pashtuns</span> (the predominate tribal group in Kandahar comprising the vast majority of the police there) who often seemed oblivious to requests for straight lines and an orderly procedure through the stations of the medical evaluation process. Most of them were shocked, and then amused to the point of distraction, that they were expected to collect and then give to a stranger a sampling of their urine. As soon as some of them learned I was a physician, they left whatever stage of processing in which they found themselves to tell me (in unintelligible <span class="blsp-spelling-error" id="SPELLING_ERROR_5">Pashtu</span>) about their stomach pain, or headache, or immediate need for a vitamin injection (a very popular therapy in Afghanistan) or intravenous fluids.<br /><br />A serious architectural design flaw, which added to the overall confusion, had the base store and barber shop located along the same hallway as the medical clinic. The screening process began with a line for the urinalysis station outside the building, as the Afghans went to outdoor portable toilets to collect their specimen; but often during the day I had wayward trainees who had left their respective groups elsewhere on the compound for a trip to the store or barber (neither of which kept <span class="blsp-spelling-corrected" id="SPELLING_ERROR_6">discernible</span> business hours), thus mixing themselves with the class I was trying to move from urinalysis to the clinic proper for an exam. I found myself yelling in <span class="blsp-spelling-error" id="SPELLING_ERROR_7">Pashtu</span> “<span class="blsp-spelling-error" id="SPELLING_ERROR_8">Dookahn</span> <span class="blsp-spelling-error" id="SPELLING_ERROR_9">bundee</span>! <span class="blsp-spelling-error" id="SPELLING_ERROR_10">Dookahn</span> <span class="blsp-spelling-error" id="SPELLING_ERROR_11">bundee</span>!” (“The store is closed!”) at dozens of Afghans attempting to destroy the little order I could maintain by pushing their way through the hallways to the store entrance. (Luckily very few of the policemen wanted haircuts.)<br /><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPT9zRmBIzQDWvX7bcHgdl82zsuSSu5q3HvLpr9KpFIRWvBI-i_mbfvX-ssg698K9KADegmV_wDUURgrtuptOYcqhBVLMRt6DHqOGHhHRdzOcZ-7IOop67cEgl1MBMRlDYhzwxr6Zq6BE/s1600-h/anp+recruits+close+mascara.JPG"><img id="BLOGGER_PHOTO_ID_5227347077546219298" style="FLOAT: right; MARGIN: 0px 0px 10px 10px; CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPT9zRmBIzQDWvX7bcHgdl82zsuSSu5q3HvLpr9KpFIRWvBI-i_mbfvX-ssg698K9KADegmV_wDUURgrtuptOYcqhBVLMRt6DHqOGHhHRdzOcZ-7IOop67cEgl1MBMRlDYhzwxr6Zq6BE/s320/anp+recruits+close+mascara.JPG" border="0" /></a>Many <span class="blsp-spelling-error" id="SPELLING_ERROR_12">Pashtun</span> males darken their eyelashes with a black ash that leaves them looking as if they have applied mascara. American military males, often homophobic and quick to chafe at customs that they perceive to be emasculating, sometimes interpret the custom as simple beautification by one male to attract another. Homosexual practices, while not discussed openly, certainly are <span class="blsp-spelling-corrected" id="SPELLING_ERROR_13">prevalent</span> among Afghan males; but the <span class="blsp-spelling-error" id="SPELLING_ERROR_14">Pashtuns</span> darken their eyelashes in belief that the practice strengthens their eyesight. Or improves already weak vision. The darkened eye <span class="blsp-spelling-error" id="SPELLING_ERROR_15">adnexa</span> might decrease the glare bombarding the eye, especially in an environment like southern Afghanistan where the sunlight and glare bound toward your face from every direction. So the practice is no different from a baseball outfielder applying a thick stripe of black greasepaint underneath his eyes before a game. The difference is that a <span class="blsp-spelling-error" id="SPELLING_ERROR_16">Pashtun</span> male maintains his darkened eyes no matter what he is wearing, even if he is sporting a police uniform.<br /><br />I learned during my brief time in Kandahar that the <span class="blsp-spelling-error" id="SPELLING_ERROR_17">Pashtuns</span>, at least the men willing to join the police force, love to entertain and to be entertained. They laughed when I attempted to speak <span class="blsp-spelling-error" id="SPELLING_ERROR_18">Pashtu</span> to them (“Stan am <span class="blsp-spelling-error" id="SPELLING_ERROR_19">Najibullah</span> <span class="blsp-spelling-error" id="SPELLING_ERROR_20">dee</span>?” – “Your name is <span class="blsp-spelling-error" id="SPELLING_ERROR_21">Najibullah</span>?”) and shadow-boxed with the three police named <span class="blsp-spelling-error" id="SPELLING_ERROR_22">Mohammed</span> Ali (although I don’t think any of them were familiar with The Greatest of All Time). They joined me in <span class="blsp-spelling-error" id="SPELLING_ERROR_23">preemptively</span> shouting “<span class="blsp-spelling-error" id="SPELLING_ERROR_24">Dookahn</span> <span class="blsp-spelling-error" id="SPELLING_ERROR_25">bundee</span>!” to anyone approaching the building who presumably was heading for the (usually shuttered) store. They laughed with me as we watched one of their colleagues drink five bottles of water before he was able to urinate. (Dehydration was the norm amongst the Afghans there.) You never would have guessed, observing what I did during the process, that the <span class="blsp-spelling-error" id="SPELLING_ERROR_26">Pashtuns</span> are the ethnic group from which the Taliban sprung.Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com0tag:blogger.com,1999:blog-288948379394923861.post-7676993078591510692008-07-24T19:45:00.001-07:002008-07-25T06:32:20.385-07:00Kandahar: Desert heat and the Taliban nearby<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNLOkqZ6LRAczOysOMf8AhEF7z1D-G_KUyLrwefDxIeUj39k5LrpTziw8oEst0Rp8ghSzThTIGnga6Ek2qed69nKlF8YLKcEXA16aIdVDJ3M9xR-8JNvT2zfveIHajUsVtT9TIrN4pgx8/s1600-h/scorpion+avenue.JPG"><img id="BLOGGER_PHOTO_ID_5226942788070293490" style="FLOAT: right; MARGIN: 0px 0px 10px 10px; CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNLOkqZ6LRAczOysOMf8AhEF7z1D-G_KUyLrwefDxIeUj39k5LrpTziw8oEst0Rp8ghSzThTIGnga6Ek2qed69nKlF8YLKcEXA16aIdVDJ3M9xR-8JNvT2zfveIHajUsVtT9TIrN4pgx8/s320/scorpion+avenue.JPG" border="0" /></a> <em>Photograph</em>: Main Avenue. Actually, the compound's only avenue.<br /><div></div><div></div><div></div><div><br /><br /><div>The 1965 movie “The Hill” depicts a British prison constructed in the sands of the Libyan Desert to house deserters and other miscreants whom the Brits believed had disrespected their royal army. The hill, for which the movie is named, is a manmade construction in the middle of the brig that the prisoners climb as punishment for infractions or lax discipline. What was most memorable for me about the film, however, was the cinematography that captured the white heat and merciless sun of the desert: rarely did a scene show shade, the Brits were forever drenched in perspiration, the walls of every building were a bleached white, the sand and rock covering the ground looked like hot blanched charcoal … as I watched the film, on television, I instinctively reached for my sunglasses as I felt my retinas might be simmering.<br /><br />Kandahar, Afghanistan, where I have been the past week, could provide the setting for a sequel to “The Hill” should the Afghan government ever decide to promote movie production as a revenue source for the country. The days here begin temperate at 75-80 degrees, but the pleasantness ends at about 06:00 when the southern Afghan sun burns through any lingering haze and begins to bake the earth below it. The temperature most days has reached 110 degrees, sometimes 115. Many people comment that “it’s a dry heat,” something akin to a “clean gunshot wound.” Adding to the comfort is the flame-resistant uniform issued to us that seems to bestow protection by keeping your skin so warm that any additional heat and fire results in a relatively minimal and painless aggradation in temperature.<br /><br />The base where I temporarily am working is a relatively small (150 x 200 meters) collection of faded tan sheet metal buildings and plywood shacks the color of newsprint completely bleached by the sun. An asphalt driveway runs the perimeter of the base, but a few inches of loosely packed gravel cover the rest of the ground. Your steps produce a crunch and pop as you ambulate around the grounds, fooling your ears into thinking that they are inches from a very large bowl of Rice Krispies with new milk added. Shower trailers are available, although they now have no electricity as last week a guard from a private security firm died after electrocuting himself while bathing in a stall with improper wiring. Such a small base offers few amenities, but for what it lacks in comfort it compensates with excitement.<br /><br />The first night featured parachute-slung flares dropped within 500 meters of the compound’s walls to illuminate the surrounding fields for special forces units hunting the Taliban fighters who use the area to launch rockets at a large nearby airfield. My compound hasn’t been targeted directly, and soldiers here pass the story that a local warlord owns the property on which the base sits and put out word that his land, for which Americans supposedly are paying an outrageous rental fee, will be left unscathed. Although I have no doubts that warlords continue to exercise considerable power throughout Afghanistan, I find it difficult to believe that the Taliban would be so cooperative. The insurgents come very close to the compound and induce reactionary measures from coalition forces nearby, threatening damage in the warlord’s neighborhood. Also, the land on which this compound sits is an expanse of sand and rock, which had little to no development until Americans built a base. The supposed warlord/landlord has no infrastructure upgrades he needs to preserve.<br /><br />My belief is that the rockets the Taliban typically fire at our bases are not exactly laser-guided missiles; and the insurgents are happy if they can place the ordnance anywhere within the wall of a compound. As this base is extremely small, especially when compared to the nearby airfield, the Taliban chooses to ignore it as one of their rockets, if at all wayward, would likely miss the compound altogether.<br /><br />The excitement continued the next morning as I awoke at 05:45 to two explosions followed by machine-gun fire from one of the compound’s guard towers. I had planned to jog around the base perimeter at 06:00 or so, but delayed the run as the gunfire from the tower continued intermittently for the next 30-45 minutes. No alarm sounded on the base, and there was no assault on the walls, so I went to breakfast and chuckled when I saw that “Natural Born Killers” was playing on the large screen TV ubiquitous throughout US military dining facilities and seemingly preprogrammed to play, at high volume, only action films that feature gunfire and gore.<br /><br />As I exited the dining facility I saw three Chinook helicopters descending as they flew over the base, and several people standing on a platform peering over the compound wall. I scurried up to the platform in time to see the helos disgorge soldiers in the mud-brick village only 500-750 meters from the compound, in the direction of the explosions I heard earlier that morning. The aircraft lifted off after a short time, and I couldn’t discern any more activity in the distance. Only then did I take notice of a terrible stench pervading the air around me; and, after looking more closely at my “platform,” discovered that I was standing atop a sewage collection tank, and next to a venting pipe open to the waste below and emitting miasmic vapors. </div><br /><div><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm9vbTl2s6U-f5xwAd5rW_xRzo5YIWq_bGXFIiB0UXIjCFch4Ja_9ghzQvLawwJ9T_VgK3s5CrDRqMG59weQiJAAghmVUlMwW29mRXfVlmIOpZISJxxA3nEaAWG0WBI5cgcRbgxmJ7WC4/s1600-h/me+on+septic+tank+op+from+rear.JPG"><img id="BLOGGER_PHOTO_ID_5226941908698045714" style="CURSOR: hand" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm9vbTl2s6U-f5xwAd5rW_xRzo5YIWq_bGXFIiB0UXIjCFch4Ja_9ghzQvLawwJ9T_VgK3s5CrDRqMG59weQiJAAghmVUlMwW29mRXfVlmIOpZISJxxA3nEaAWG0WBI5cgcRbgxmJ7WC4/s320/me+on+septic+tank+op+from+rear.JPG" border="0" /></a><em>Photograph</em>: Me atop OP Septic Tank.</div><br /><div><br />I spent the remainder of my first full day on the compound wondering just how hot the place can possibly get, and was not surprised at nightfall to see more parachute flares. But the night and the next day waere quiet, until another loud explosion in the near distance sounded in the early afternoon. I learned later that a suicide bomber started to approach a convoy of vehicles from this compound when an Afghan policeman recognized the danger and shot him, but not before the bomber detonated his explosives. He was too far from the American vehicles and soldiers to cause them any damage or injury, but a local Afghan woman and a child reportedly died in the blast.<br /><br />I’ve heard soldiers deployed to Kandahar and nearby Helmund, the heart of the Pashtun ethnic group and a stronghold of the Taliban, openly mock the relative safety and luxuries of “cosmopolitan” Kabul, as if those of us in the nation’s capital are enjoying the Afghan equivalent of a Sedona spa while they remain in the south of the country fighting the real war. Their vision of Kabul doesn’t correspond to reality, but I cannot blame them for overestimating the comfort and safety of their comrades to the north as I have been in Kandahar only one week, and I can report first-hand that it’s not pretty down here, and too often frightening as well.</div></div>Ronald Willy, M.D.http://www.blogger.com/profile/05972225059979526361noreply@blogger.com1