Afghan Ronny

Lessons in Cultural Differences

2009-02-16T09:09:00.000-08:00

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

Princess: What sea?

Chance: The Gulf.

Princess: The Gulf?

Chance: The Gulf of misunderstanding between me and you …

Tennessee Williams, Sweet Bird of Youth

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

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

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

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

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

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

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

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

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

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

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

Latest Taliban Atrocity: Coordinated Murderous Attacks in Kabul

2009-02-11T19:12:00.000-08:00

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

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

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

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

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

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

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

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

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

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

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

Afghan Ronny in the Social Justice Press

2009-01-31T21:30:00.000-08:00

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, Journeys. Below is the submission, included here without the minor editing needed for publication. (Afghan Ronny is never short of words.)

Prayer in a Time of War

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.

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: Don’t underestimate the protective power of God toward those who pay the Lord homage.

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.

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?

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.

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.

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.

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.

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.

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?

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?

Article first published in Journeys, the periodical of the Jesuit Volunteer Corps: East, Vol 32, No.1, Fall 2008.

Afghan Ronny on the Radio

2009-01-24T08:29:00.000-08:00

I 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.

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.

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.

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.

The situation at Camp Eggers

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.

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 in extremis 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.

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.

http://www.in.gov/sos/desk/AfghanChildrenToys.html

A short statement on official visitors to places like Afghanistan

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.

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.

Now about the radio appearance

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.

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.

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.

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.

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.

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.

Viagra apparently NOT a silver bullet for intelligence agents

2009-01-12T06:53:00.000-08:00

The headline in the Washington Post was sure to draw attention:

Little Blue Pills Among the Ways the CIA Wins Friends in Afghanistan*

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.

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.

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.

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.

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.

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.

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.

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.

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.

*Washington Post article, December 26, 2008

It Cannot Get Much More Desperate Than This

2009-01-03T08:26:00.000-08:00

You’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.

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.

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.

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.”

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.

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.

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.

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.

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 don’t 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.

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.

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.

A Visit to the Slaughterhouse

2009-01-01T04:47:00.000-08:00

WARNING: 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.

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.

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.

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.

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.

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.

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.

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.

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 The Jungle 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.

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.

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!”

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.

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.

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.

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.

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.

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.

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.

Christmas in Kabul

2008-12-30T09:12:00.000-08:00

I 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.

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.

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.

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.)

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.

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).

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.

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.

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.

A Holiday to Forget: Part II

2008-11-30T04:03:00.000-08:00

See previous blog entry for Part I

I am a fan of war movies, especially those films depicting soldiers in World War II as they sit around airfields and flight terminals waiting for their transportation to battle. I always assumed that such moments, as devised by Hollywood, paid true testament to the moments when soldiers bonded, when they solidified their camaraderie and fellowship; when banter was witty and biting and strangely intelligent, given the circumstances. After sitting with other uniformed personnel for several hours in an airport terminal on Thanksgiving morning, I learned that I had been mightily deluded by those scenes. Most of us that morning were tired, shrill, impenetrably absorbed in our own personal discomfort, slightly foul of odor, and unable to string two sentences together without a few F-bombs littering our grammar.

The movies often show soldiers in similar situations playing cards and throwing dice, the financial fin de siècle behavior brought on by war and the uncertainty of survival and return to the conventional existence of their homeland. None of that took place on Thanksgiving morning either, as the DoD has made it a point in America’s most recent wars to prohibit any vice that might provide measurable entertainment and relief to the troops. Besides, I am an officer and most of those willing to wager their salaries would have been enlisted. It isn’t proper that I gamble with them, especially if I am ready to take their money (which I would be). I admit that in the past I have ventured into a few low-stakes games of chance with younger enlisted personnel, and I have found them as a group to be rather reckless with their betting and unwilling to allow the odds to direct their wagering; and although I could rely on them for regular income, it’s best that I keep my distance, sort of like Vegas gamblers remain isolated (supposedly) from the athletes on whose performances they bet millions.

But gambling wasn’t forefront on my mind as I sat through my sixth hour at the terminal Thanksgiving morning. Instead, I was wondering when I would be able to get myself a bit of lunch. Thanksgiving is a holiday that prizes gluttony, and I had yet to take a bite of anything. Had I been at my mother’s house, I already would have eaten a large breakfast and most of the skin off the family turkey that sits freshly roasted and preening in the kitchen before the early afternoon feast. The instructions from our surly “flight coordinator,” however, were that we were not to leave the departure gate as we might be called to board an alternative flight at any moment. The reality of military travel is that often you will wait hours (if not days) for transportation, only to be given three minutes to board a plane or bus once the vehicle arrives; and if you are not present to board the craft due to an irresponsible absence brought on by attending to such trivial personal desires such as an urgent need to void or to procure a sandwich for your only meal of the day, the transportation simply leaves without you.

Finally, mercifully, at 12:30 – after 6 ½ hours of waiting for a flight – our surly “flight coordinator” confirmed that we had no transportation that Thanksgiving Day, and excused us with instructions to grab our luggage from the pallet on the flight line and return the following morning at 06:00. This time I remembered the advice often given surgery residents to help them survive their demanding clinical training regimen: Sleep when you can, eat when you can, make love when you can, and don’t f--- with the pancreas. General Order #1 forbids most sexual intercourse in theatre, and I had no intention of opening anyone’s belly to play with the potentially self-autolyzing organ that is the human pancreas; but I was very tired and I was very hungry, so I made my way to the transient billeting office anticipating a pleasant Thanksgiving nap followed by a proper holiday meal. I had no intention of hauling both a backpack and my large duffle bag around that day and early the next morning; so I removed my sleeping bag from the duffle and left the remainder of my belongings under a tent outside the terminal, thinking that I likely would retrieve them the next morning, but not really concerned that my government-issued winter gear might disappear overnight. I looked like a sad, green, slightly underweight, hang-dog Santa Claus as I walked to the billeting office with the unfurled sleeping bag hanging over my shoulder, a few items for the night lending it only the slightest girth.

Even though I had logged only a minimum of intermittent and fitful sleep the past thirty hours, I opted for a Dairy Queen mushroom cheeseburger before I passed out, as I imagined in horror that I might sleep through the base dining hours and awaken late at night famished and without any meal options. (Those who know me well know that my greatest fear is not poverty or death, but sustained hunger.) I also remembered the advice for the budding surgeons: Eat when you can. Some of you might be surprised to learn that American fast food chains such as Diary Queen have outlets on bases in Afghanistan. Let me assure you that these restaurants – usually trailers painted with the familiar chain symbols and logos – often are similar in name only to their counterparts found on US soil. One Pizza Hut I recently visited offered mozzarella that tasted like fish; and the Dairy Queen near my tent produced a burger smothered in an herbed cheese with the consistency and taste of Elmer’s glue mixed with horseradish. The cheese concoction, when it dripped off my burger, literally bonded together several of my French fries.

The dreadful meal at least provided the sustenance for which my body, very unaccustomed to fewer than four meals per day, had been crying since early in the morning. The beef and fried potato glue ball in my stomach also absorbed the last bit of energy I possessed that afternoon, and I crawled into my winter weight sleeping bag without realizing until I awoke a few hours later that the temperature of the tent approached 95° F. When I suddenly found myself conscious but simmering in a profuse sweat, I thought that perhaps one of the low-flying jets overhead had released fuel on me and my tent mates. I realized quickly, however, that I smelled like the mat from a summer wrestling camp, not a gas pump; and only then did I notice the hot breeze circulating within the tent. The roasting air which had turned the tent into the world’s largest convection oven emanated from two cylinders, one at each end of the rectangular tent, that were almost two feet in diameter and reminded me of the spouts of the snow machines found at ski resorts; although instead of spewing frozen precipitation, these pipes belched heat.

Of course I had not brought a towel with me to the transient tent, or any other implement suitable for mopping the sweat off myself, so I stepped outside in my boxer shorts and prayed the cold, dry Afghan air would evaporate the solid sheen of perspiration I was carrying before it froze into an ice casing. Because women and other horrified personnel walked by the tent, I couldn’t stand outside barely covered for long. So I went back inside, recalled that it was Thanksgiving Day, confirmed that it was dinner time and a holiday meal awaited me at a base dining facility, and slipped my uniform over my still moist frame. As I made my way to the turkey, I stopped at a latrine trailer and dried with paper towels what skin I could reach underneath my uniform.

I must have been in a foul mood, or simply lacking the appropriate holiday spirit, because I have to report that I found the façade of a Thanksgiving meal and celebration constructed by KBR, the food contractor, both depressing and irritating. The turkey offered was the same processed variety we see weekly, with curiously identical slices segregated only by light or dark meat. I instead opted for a slice of beef called Steamship Round, which was a Chevy-sized chunk of meat impaled with a large bone. It looked very similar to what I often encounter when I lunch with Afghans, except the Steamship was much larger than the “leg of something” that the Afghans typically serve. It tasted similar, however. The dining room was littered with paper Thanksgiving decorations that gave the entire facility the aura of a very large elementary school cafeteria. A five-piece brass band played such festive holiday tunes as “Hold That Tiger” and “Get Back (to Where You Once Belonged).” I like to engorge myself with hot buttered rolls on Thanksgiving, but I was unable to do that as I couldn’t find the rolls and KBR makes only margarine available.

Probably my fatigue and sour mood fouled the meal more than anything KBR prepared. My repast was certainly the smallest, fastest Thanksgiving dinner I have ever eaten. I really wanted more sleep at that early evening hour anyway, so left the dining hall armed with a couple of cups of ice that I thought I might need later, and returned to my cot in the broiler that was my quarters for more sleep, very pleased that such a festive holiday was almost over.

A Holiday to Forget: Part I

2008-11-29T06:03:00.000-08:00

I now consider myself a seasoned military traveler in Afghanistan, accustomed to the delays, inconveniences and mysteries inherent to flight schedules in a war zone. So I take full responsibility for the frustration I encountered when I tried to travel via air on the Thanksgiving holiday. I was expecting too much. I was suffering under the illusion that the local airlift command worked toward the goal of transporting passengers with a minimum of pain and suffering.

My travail began the day prior to Thanksgiving, when I left my base at 05:45, arrived at the airfield at 07:00, learned that my flight plan would be available at 10:30, and finally confirmed mid-morning that my travel was not scheduled to begin until the next morning when I was expected at the terminal at 06:00. At that point, more than 18 hours before I needed to report back for my flight, I should have simply trudged up the street three hundred yards to the transient housing office, where I would have been assigned a cot in the transient passenger tent located almost one mile from the terminal.

A night in the transient tent did not seem too appealing to me at the time for several reasons. That morning when I would have checked in for a cot, I could have utilized the convenient base shuttle to take me and nearly door-to-tent; but the following morning, when I was expected at the terminal before sunrise, the shuttle would not yet be running. I would then have to wrap my duffels about myself and hump (as the infantry says) the entire distance, negating any hygienic advantage a pre-flight shower might have brought me.

Additionally, I try always to follow the advice of my college roommate Mike Monticello who admonished me to “travel heavy” whenever possible. Mike, while an undergraduate, owned what I think was the last produced steamer trunk from Brooks Brothers into which he carefully folded his cotton and linen wardrobe for trips as brief as an overnight stay at his parents’ place ninety miles away. I often pay tribute to Mike when I travel by loading my bags with whatever I might possibly need, to include a laptop computer, bottled water, several notebooks, a few hardcover medical reference books, a selection of exercise gear, sundry laundry products … More than once I’ve been able to offer assistance to a friend – who had ridiculed me earlier for over packing – by providing Internet wireless access, a chapter from Harrison’s Internal Medicine, and a shot of fabric softener.

I also had less than fond memories of the last time I attempted to sleep in the transient tent, which is located at the runway terminus for the busy airfield. Permanent housing for airbase personnel surrounds the transient tent, and I’m not sure how those military personnel adapt to sleeping through the noise as all night long the pilots of F-16 and Prowler jets ignite the afterburners for their craft at the end of the runway, before they are even airborne, to get speed and gain a safe altitude quickly (up and away from any enemy ground fire). The sound of this maneuver for a newcomer attempting slumber in the transient tent simulates a locomotive barreling through the canvas and overhead of the exhausted recumbent. (I recently learned from an aviation crew member that the Prowler, surely the most inappropriately named acquisition in the history of modern warfare production, is the louder of the two craft.)

Instead of a night in the transient tent, I opted to lounge in the USO building located just across the street from the terminal and open throughout the night. I figured I would be able to nap there, and even use the half-day to send one or two emails utilizing the world’s slowest wireless internet service that the USO offers. After all, I had my laptop. The USO, I learned, is comfortable, but only for brief periods of time. The facility caters to the younger military troops, as well it should, which means that loud Hollywood action flicks blare throughout the building day and night, as do large screen video game devices strategically placed to foil any attempt by a patron to read a book or even converse with a neighbor. The chairs look inviting, but I found they were not designed to support comfortably a forty-two year old spine. Also, once you sunk into the soft cushions, you found yourself immersed in the lingering musky vapors of seven years of US infantry who have transited through the airfield.

I have spent more than twenty-four straight hours on duty at a hospital, and I am a field grade officer in the United States military, so I was able in the early morning to ignore my fatigue, brush my teeth, wash and shave my face, and then report to the terminal at 06:00 ready for my flight. My plan was to sleep on the plane, which I figured we would load by 08:00 at the latest. I didn’t bother scrounging breakfast anywhere, as I deluded myself into believing that lunch would surely be available shortly after noon, when I expected to be at my destination. At 09:30, though, I found myself still cordoned at a departing gate with 60-70 other passengers, wondering just what the hell was going on with our flight; and if anyone in the terminal was prepared to give us any information on when we might be allowed to leave the terminal, either via the runway or the entrance door.

About that time a gate attendant brought in several boxes of Pop Tarts and breakfast cereal (without any milk), a courtesy that is in fact a terrible prognostic indicator for a military traveler hoping to move from his present location. And shortly after the improvised Continental fare landed on the dusty concrete of the departure gate floor, we got word from our surly “flight coordinator” (who had been not-so-mysteriously absent the previous 2 ½ hours) that our plane had been grounded due to mechanical problems, but that she was trying to locate another craft for our journey. She gave us this holiday news in a clipped, imperious tone as if we were inconveniencing her. It was typical of the military customer service approach, for which I will suggest to the Department of Defense adopt the motto “How can we not help you?”

Part Two of a "Holiday to Forget" coming very soon (like tomorrow).

Problems with Procurement

2008-11-12T07:39:00.000-08:00

Many practitioners of modern medicine are quick to describe physicians and other healthcare “providers” as much more than simply skilled technicians able to manipulate human physiology with interventions that bring cure to maladies and injury. Some of us wish to retain the appellation of “healer,” signifying a more holistic approach to medicine that considers the patient’s entire state of good health, and not merely the absence of disease, as the therapeutic target. I agree that the ultimate goal of health is truly wellness, but I also know that I and most other physicians I know are really trained manipulators; and unless we consider ourselves faith healers, we aren’t very good at our jobs if we don’t have a considerable arsenal of pharmaceuticals, prosthetics, surgical screws and laboratory tests available for diagnosis and treatment. (I have yet to meet an internist able to reduce blood pressure significantly with conversation and meditation; or a surgeon successful in staunching internal bleeding with prayer and hypnosis.)

Few physicians in Afghanistan have access to even a fraction of the array of goods that an American physician relies upon for practicing medicine, a dearth that severely limits the care that competent Afghan physicians are able to offer. Even the influx of US government dollars does not solve the problem of scarce material resources for care here. Almost every component of Afghan society decayed and fell apart over the last forty years, including the commercial sector. You might have the money to buy laboratory reagents from the United Arab Emirates or a European supplier, but there is no reliable refrigerated transportation service in Afghanistan. In fact, those supplies, necessary for any modern hospital to support clinical diagnoses and treatment, might not ever make it through Afghan customs, even if they reach the border of the country. For a few weeks a colleague has been trying to determine if a cache of laboratory reagents is sitting unaccounted for – and likely spoiling – in a customs’ warehouse in Kabul or at a border station with Pakistan. Or if the supplies simply disappeared somewhere between the manufacturer’s warehouse and the designated Afghan hospitals.

The shipment might have been high jacked coming through Pakistan. The AP reported today that gunmen along the Khyber Pass attacked a convoy of trucks carrying “military vehicles and other supplies” (lab reagents?) destined for US forces in Afghanistan. I’m sure the bandits who pulled the heist are thrilled with the Humvees and trucks they captured; but if they took the time to examine the rest of the booty on the convoy and discovered vials of chemicals used to determine blood cholesterol levels and hundreds of urine pregnancy kits, they likely chucked these items into a Tora Bora ditch.

If the supplies you order do make it into the country, you have to be careful about how you distribute them. Highway banditry is the rule in Afghanistan, even moreso than in Pakistan. Local truck drivers typically consider every major roadway in Afghanistan a toll road, with the fare calculated and extracted from whatever goods comprise their loads. It’s a system similar to what the Mob ran at JFK Airport for years, and highlighted in the movie Goodfellas. So you should assume a rather high percentage of cargo loss if you send out a convoy of supplies to traverse Afghanistan.

Sometimes you can arrange direct delivery of supplies to a district hospital or clinic through a nearby airport, but you then risk incomplete accounting from the hospital personnel in the regions far from Kabul, as those folks just might pilfer a pallet or two of goods from the delivery and then report to the central accounting agency in Kabul that certain supplies never arrived.

The Recurrent Problem with Local Vendors

The United States government has a policy that American military personnel utilize local vendors when possible to secure the supplies we need in order to operate hospitals and clinics. The rule is reasonable, with the rationale that bolstering local Afghan businesses will boost the overall Afghan economy. Considering the prices many of these local vendors, who are cognizant of the US government rule favoring them as procurement agents, the American taxpayer is boosting certain sectors of the Afghan economy quite nicely. I have seen medical products of such low-quality and high-price that they would make even the most unscrupulous US military contractor blush with shame: flimsy nasopharyngeal airway tubes for $30, plastic catheters for $20, malleable arm splints for $60. And that’s the cheap stuff. I’m not sure how much x-ray film and surgical screws cost here, but the price tags would surely rival the infamous $400 hammer and $600 toilet seat that the Pentagon purchased in the 80s.

We may not be exporting stellar business ethics to the Afghans, but we are certainly developing an entrepreneurial spirit among the commercially aggressive men angling for whatever US business exists wherever they can find it. Builders, suppliers and vendors here often will promise that they can construct or deliver anything you require, regardless if they have ever contracted for the service or material before. I have seen business cards that read “Provider of medical equipment, and building foundation construction experts,” and “Shipping all your business supplies, with pharmaceuticals, and superior auto service.” Think that a US agency needs another service that you might be able to provide? Simply add that “specialty” to your business card, bid for the contract, and worry about delivering what you promised after you are chosen for the job.

Many of the Afghan businesses are experienced and honest with respect to their abilities, but contracting and quality problems arise far too frequently with local businesses. A medical technician’s school, funded by the US military, ordered through a local vendor a mannequin to teach resuscitation techniques, and a few different skeletons for anatomy instruction. The Afghan vendor assured the school that he could produce quality goods. The resuscitation mannequin delivered was simply a doll’s head. One of the instructional skeletons was similar to the paper decorations that litter most elementary schools before Halloween. Another skeleton was a poster with detailed anatomical references such as “upper leg bone.” A few of us joked that, for surgical instruction, we should order the game “Operation.”

Last month an order of more than $1 million in desperately needed pharmaceuticals finally reached a Kabul hospital. When the US agent responsible for the purchase went to inspect the shipment, he found that the local vendor had substituted cheaper drugs of dubious quality from China and Pakistan for the order, even though the contract specified pharmaceuticals only from reputable manufacturers in the United States and Europe. The Afghan quality assurance agent at the hospital happens to be a friend of the vendor, and appeared willing to stock the pharmacy with the inferior goods, almost certainly after a nice bribe from his buddy. If the US agent hadn’t caught the fraud, patients would have been exposed to poor quality therapeutics and the vendor would have made a profit considerably higher than the windfall he already was assured had he adhered to the contract.

An Afghan proverb translates into something like “If you wait 100 years for your revenge, you have moved too quickly to exact your just retribution.” The Afghan mind still puzzles me; and I don’t fully understand the adage as the average life expectancy in Afghanistan falls somewhere in the mid-40s. I only hope that the average Afghan, who would be happy with a modicum of modern medical intervention, doesn’t have to wait much longer for a little bit of healthcare and a national business ethic that isn’t grounded in thievery.

Critically Ill: Afghanistan's Healthcare System (Part Three)

2008-10-31T03:22:00.000-07:00

This is the third and final article illustrating several of the challenges encountered in building a functioning healthcare system in Afghanistan.

Hopefully your village has a medical clinic, and hopefully the clinic is more than just a white building

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.

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.

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.

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.

How much is that pacemaker in the window?

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.

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.

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.

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.

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.

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?”

*Atul Gawande, Better: A Surgeon’s Notes on Performance, p. 241.

Critically Ill: Afghanistan's Healthcare System (Part Two)

2008-10-23T23:36:00.000-07:00

This is the second article illustrating the challenges encountered in building a functioning Afghan healthcare system.

There is No System Here: The Example of Medical Waste Disposal

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.”

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.

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.

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.

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.

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.

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.

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.

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.

Critically Ill: Afghanistan's Healthcare System (Part One)

2008-10-15T09:22:00.000-07:00

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.

“Physician” is More a Title Than an Academic Degree

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.

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.

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.

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.

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.

If You Paid Me Like an Interpreter, I Would Practice as a Doctor

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.

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.

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.

COIN for the Realm: Novel Approaches to Counter-Insurgency Operations in Afghanistan (Part Two)

2008-09-21T08:45:00.000-07:00

(This is the second article in a two-part series. See the previous post for part one.)

Operation Frigid Air

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.

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.

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.

Perpetual Star Strategy

One of the most popular television shows in Afghanistan is Afghan Star, a glorified talent show modeled on American Idol. The founder of Tolo TV, which produces Afghan Star, 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 Afghan Star in March. One interpreter told me that it not only was his grandmother’s favorite television show, but the only program she watched.

The United States should assist in producing a continuous run of Afghan Star, 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 Afghan Star on the single small television available in their locale. The Afghans who did not watch the last season of Afghan Star 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 Afghan Star would leave the vast majority of the country too mesmerized by the national singing talent to ponder subversive activity. The interest in Afghan Star 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.

A Professional Approach to Finding Osama bin Laden

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.

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.

COIN for the Realm: Novel Approaches to Counter-Insurgency Operations in Afghanistan (Part One)

2008-09-19T08:35:00.000-07:00

Photographs: 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.

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.

The Polaroid Lure

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.

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.

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: 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. 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.

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.

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: 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. 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.

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.

(Next blog post: COIN (Part Two, including Operations Summer Freeze and Afghan Star, and a strategy to find Osama bin Laden.)

Mazir-e-Sharif: A Trial with Wind, Dirt and a Troublesome Prostate

2008-09-16T08:09:00.000-07:00

Whoever 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.

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.

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.

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.

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.

Earthquake!

2008-09-09T03:46:00.000-07:00

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.

The Afghan officers’ response was in keeping with the cultural notion of inshallah, 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 inshallah myself for a few minutes.

I had encountered the concept of inshallah 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. “Inshallah,” they claimed, indicating that God simply willed the recovery; and why was this American-construction-supervisor-turned-paramedic so proud of himself?

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.

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.

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.

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, inshallah.

An Afghan Lunch

2008-08-30T09:01:00.000-07:00

Interview for a job in the United States and there are several critical pieces of information you want to ascertain from your prospective employer, such as expected salary, retirement plans, and annual vacation time. Health insurance benefits will likely be forefront in your mind as well, and deserving of a query. In Afghanistan, a primary question for an employer is: Does this job provide a proper lunch?

Afghans traditionally take bread and tea for breakfast, followed by a large lunch and then a small supper. Most Afghans are poor, unfortunately, so what constitutes a large lunch varies by income; but also by job. Those Afghans blessed with employment, and especially those working for government ministries, the military, and large businesses, usually enjoy a lunch provided at the workplace; and that meal is, by far, the largest repast of the day for most Afghans. The lunch benefit is so important that an Afghan-American surgeon who has returned to his hometown of Kabul to start a medical clinic after more than 35 years of practice in Florida recently told me that he has problems recruiting qualified staff as his budget does not allow him to buy his employees lunch.

I’ve kept abreast of news reports detailing recent food shortages in Afghanistan and many other poor sectors of the planet; but if you sat down for the midday meal, as I have done, at a military medical clinic or an Afghan ministerial office, you would think you were living in the Fertile Crescent during a period of bumper crop harvests. The typical lunch I’ve seen (and eaten) begins when you receive a plate of rice voluminous enough to feed a small Chinese village. Often the rice will come as a traditional palao and include a combination of raisins, cherries, carrots and meat. The palao usually carries the aroma of cooking oil and butter indicating a quick light fry prior to presentation (a process that we all know makes everything taste better). Whatever the type of rice offered, your serving will be just short of a bushel.

If you stand up to peer over your serving of rice and scan the rest of the table, you will see several other standard Afghan dishes including a very tart yogurt that is slightly curdled and feared by many Americans as pasteurization has not yet made it across the Khyber Pass as standard practice in the dairy industry of Afghanistan. I like to use the yogurt, which is unflavored, as a condiment for my rice and meat because I like the rich tangy bite it provides. No Afghan has yet confronted me on anything improper about mixing dairy and flesh, perhaps because the Islamic dietary laws apply here, not the Jewish.

Stewed vegetables and perhaps lentils will also grace the table. Okra seems to be popular, especially a soft, moist okra that tastes slightly of cooking oil and butter, indicating a quick light fry prior to presentation (a process that we all know makes everything taste better). You might also have before you a thin soup with carrots and noodles.

Certainly you will have a plate of naan flat bread, and larger institutions have their own traditional naan ovens where bakers (often teenage boys working for a couple of daily meals and perhaps a bit of cash) knead and flatten the dough before sticking it to the underside of the ceiling of a wood-fired stone oven. At one clinic I visit regularly, my first stop upon arrival is at the house naan bakery for a piece of hot bread fresh from the oven. It’s my Afghan equivalent of entering a Krispy Kreme donut shop when the hot light is on. The edges of the naan are thicker and softer than the middle of the disc, which is thin and crisp. I’ve discussed with a couple of naan experts the possibility of baking full pizzas just as they bake the bread, as I thought that might be a unique and marketable Afghan twist on the already prevalent stone-oven pizza concept, but we cannot devise a method to keep the toppings from falling off the dough into the fire once the pie is inverted.

Naan at the lunch table is useful as a scoop for yogurt, a shovel for rice, and a pincer pad between your fingers for snagging meat morsels. Rural Afghans might not have any table utensils at all, and need the naan for manipulating the rest of their food. Most tables I’ve seen in Kabul feature silverware. Contemporary urban Afghans will even use their left hands to reach for naan if necessary, breaking a taboo against the cleanliness of the hand that traditionally performs necessary bodily hygiene maneuvers and therefore considered, for good reason, as unclean and not to be offered to guests in greeting or commingled with vittles.

The meat at lunch might be served in a small individual dish, cut into slender strips and mixed into the palao, or still attached to a large bone from the donor beast and sitting atop another tub of rice. I like the latter presentation best. I call it “Leg of Something,” as I’m never sure the species represented. I know what it is NOT: pork. But you can place your money on any other mammal, with goat the odds-on favorite.

The Afghans do not forget about dessert. You will see fresh oranges at lunch, along with lemons that many Afghans will slice and eat like any other citrus fruit. My favorite post-lunch treat is a peculiarly dry and slightly sweet melon, usually the size of an average watermelon, with white fruit and a yellow rind. I asked an Afghan colleague for the English name of the fruit, and he said, “We call it MELON.”

I asked if it is a certain type of melon, and he responded, “Like a watermelon, but just a MELON.”

My Dari is lackluster, at best, compared to his English. And I really don’t care what it’s called. It’s delicious, and I eat more than my share every time I find it on the table.

Taking Chai

2008-08-22T08:58:00.000-07:00

Last week I attended a meeting with representatives from several Afghan health organizations committed to developing a medical plan to respond to disasters that hit the country. Considering the earthquakes, droughts, pest infestation, brutally cold winters and military devastation that regularly affect a sizeable portion of the population, a disaster response plan is imminently reasonable. So said an eloquent representative from one of the agencies, and he then began to expound on details and initiatives crucial to the nationwide coordination of a medical response. I was impressed, as I have found it rather unusual that an Afghan official actually takes control of a project and pushes his countrymen to produce policy and procedures beneficial to the population. Unfortunately, I wasn’t impressed for too long, as shortly after he began his disquisition, he stopped and said that he would like to say more about organizing a medical response program for the country, but as his tea (served to everyone several minutes prior) was getting cold, he must sit and drink it now.

I knew that the taking of chai, as tea is known here, is an important custom at meetings in Afghanistan. I was unaware, however, that a warm cup of the beverage took precedence over the promotion of improved public health for the country.

Upon entering an office or residence or meeting in Afghanistan, you invariably will be offered a cup of chai. The tradition is testament to the Afghan custom of hospitality. Along with the chai, you usually receive a small piece of candy or a dish of nuts. The taking of chai is common and important in many Middle Eastern and Asian cultures, and oftentimes true business cannot be comfortably discussed until initial greetings and chai are complete. Chai is so much a part of the culture that an office or ministry in Afghanistan typically has one person appointed to serve the drink at meetings.

I first encountered the concept of the “chai boy” in Turkey, when I visited an uncle who is a civil engineer and was managing the construction of a freeway around the city of Izmir. I went to the worksite with him one day and sat for a meeting between him and a few Turkish contractors. Shortly after discussions began in the double-wide trailer that served as his office, a Turkish man who looked thirty-five years old entered carrying a tray laden with one cup of chai for every man in the room. I watched as this same man waited for us to finish our chai, after which he retrieved the cups and disappeared.

After the meeting, I asked my uncle why that employee didn’t stay for the discussion. My uncle, confused, asked which man I referred to. “The one who brought in the tea,” I answered.

“You mean the chai boy?” my uncle responded.

Not familiar with the term or occupation, and not yet ready to believe that a thirty-five year old man could actually support himself serving tea to engineers at a construction site, I responded, “Yeah, I guess. Your employee who brought in the tea. What’s his position here?”

My uncle looked at me as if I had just questioned the precepts of Euclidian geometry. “Ron,” he said, “That guy is the chai boy. That’s his job. To serve chai.”

At the meeting last week, a Ministry of Health chai woman charged us with chai and candy shortly after proceedings began; and when the gentlemen who suddenly found himself unable to continue with the important task of creating public health policy for Afghanistan due to a cup of rapidly cooling chai, a quick-thinking fellow Naval officer summoned the woman, somehow gesticulated the request for a fresh, hot cup of chai to the table post-haste, and then quickly served the chai to the health official who, obviously bolstered by the steaming brew now below him, took a quick sip of the just-delivered beverage and then continued on with a rather impressive proposal for mitigating the medical plight of Afghan victims of national disasters.

Another recent incident illustrates as well the propensity for Afghans sometimes to value their chai above important matters at hand. Last month I went with an American pediatrician to examine and vaccinate at his home the infant son of a very high-ranking Afghan politician. My colleague and I completed the exam, and then began to examine closely the infant’s medical record as past vaccinations were not well-documented. We hadn’t seen the record before we arrived at the politician’s home as the child’s mother maintained the chart, and we weren’t sure we would see the child again during our tenure in Afghanistan; so we wanted to review and update the record properly.

The politician’s housestaff included a young man who had recently graduated from Kabul Medical University, who told me that he hoped to matriculate to Canada soon to begin a residency in neurosurgery. He was a relative of the boy, clearly affectionate with the child, and grateful for our examination. A few minutes after we began reviewing the medical record, however, he began to shift uncomfortably in his seat. I noticed that the child’s mother had left the room, and I assumed that she had moved to the kitchen to prepare the inevitable chai. Apparently the budding neurosurgeon knew himself that chai now awaited us, as he allowed us only two or three more minutes with the record before he became so agitated that he quite literally jumped to his feet and exclaimed “Please, we must finish here! It is now time for chai.”

Canada is part of the British Commonwealth, a collection of people who, like the Afghans, take their tea pretty seriously. Still, I think that a Canadian neurosurgeon, given the choice between a taking tea break or properly documenting a patient examination, would probably choose to complete the medical record according to established standards. I’m not sure if that young Afghan physician will ever undertake surgical training in North America, but if he does he will quickly learn that if he wants chai during the workday, he’s going to have to wrap the beverage cup in a cardboard sleeve and enjoy his drink on the go.

Sitting for a Kuchi Tribal Council

2008-08-16T09:04:00.000-07:00

The Kuchi peoples are the last of the nomads in Afghanistan. They migrate with the season, maintaining a lifestyle that befuddles most other Afghans. The outskirts of Kabul host several different Kuchi settlements, usually clusters of hundreds of low-slung black tents. One of my interpreters shook his head and gave me an incredulous look when I asked him about the Kuchis. “Many of them have money. They own businesses,” he said. “But they like living in those tents.”

I recently visited a Kuchi camp east of Kabul. I was expecting to see a mobile canvas metropolis, but instead found myself in the middle of a small mud-walled village with a single, narrow street that barely accommodated my five-vehicle convoy and the five hundred Kuchi men and boys who appeared to be waiting for our arrival. 250 of these males began to direct us to various parking spaces, none of them large or secure enough for our vehicles. The other 250 were intermittently assaulting an international aid truck distributing large bags of grain (clearly another factor that drew the crowd). I was driving one of the SUVs in the convoy, and after idling among the throng of Kuchis for a few minutes – each one of them gesticulating for me to proceed in a direction different from what his neighbor urged – a few Afghan policemen with AK-47s and nasty looking sticks that resembled horse-whips literally beat people away from my vehicle, and directed me to back into a gate that opened along the walled street.

I was traveling with several other military medical colleagues and a delegation from the Afghanistan Ministry of Public Health led by the Deputy Minister. The ministry, at the urging of the Kuchis, wants to build a medical clinic at the settlement. Before we departed Kabul, I questioned why anyone would seriously consider constructing a permanent medical clinic for a group of nomads. The answer came back that Kuchis collect at this particular spot outside Kabul every year, and in fact many of the tribe intend to settle there permanently.

The president of Afghanistan, Hamid Karzai, has been trying to stop the Kuchi migrations across the central and southern regions of the country. The Kuchis are ethnically Pashtun, the same as Karzai, so he may wield some influence in convincing the Kuchis to abandon their nomadic heritage. He certainly could do without the recent political controversies involving the Kuchis and their alleged squatting on lands claimed by other ethnic groups. Over the past few months the Kuchis have been battling – both verbally and physically – the Hazara, who live and raise livestock in a couple of provinces near Kabul. Both groups lay claim to grazing lands made scarce this year by low amounts of rainfall, and both groups claim murder of their kin by the other.

The Hazara for centuries have been the abused minority of Afghanistan. They are Shiite Muslims surrounded by devout Sunnis. Moreover, they are descendents of Genghis Khan, and thus a reminder of that invader and his rampaging horde who rose from Mongolia to sweep through Asia. In what is present-day Afghanistan, the Mongols simply destroyed most of what they encountered, deposited a considerable amount of their DNA, and left a rudimentary governing military structure. But most of the Mongols left the Afghan lands shortly after they ravaged it, and rode on looking for the thrill of pillage elsewhere in Central Asia. Ironically, the Kuchis, who now are rivals of the Hazara and more than willing to use their Pasthun ethnicity (which in Afghanistan makes for considerable political muscle) to encroach upon Hazara land, may never have come to prominence at all in Afghanistan had not Genghis Khan slaughtered the sedentary tribes of the country while the mobile nomads hid in the hills and caves, waited out the invasion, and emerged later relatively unscathed. Quite suddenly, the nomads found themselves a prominent political force due to the shockingly high attrition rate for anyone standing stationary on flat land as the Mongol horseman rode by.

The entirely male Kuchi delegation that awaited us at the settlement included the group’s representative in the Afghan parliament, its mullah, and 25-30 other elders and clan leaders from the local settlement. We met in a long, narrow room one floor above the bustling street. At the head of the room sat the mullah and the Parliamentarian, flanked on both sides by the Deputy Minister, a few of his staff, and us Americans. None of the Kuchis seemed bothered that we Americans were wearing body armor and helmets, and carrying loaded M-16 rifles that we simply leaned against a wall or placed in front of our feet on the carpeted floor.

We had also left two men from our convoy at the vehicles to guard them. That is standard military procedure when parked in an insecure location. In fact, our initial reaction when we drove into the main square of the village to find ourselves surrounded by hundreds of Kuchi males in loose-fitting, traditional Afghan dress who were unable to resist the urge to nuzzle our vehicles was: This is the scenario that our combat survival instructors in the US told us to avoid at all costs. After learning that we were to meet with all the leaders of the community, however, we realized that in fact we were probably safer in that village than we would be anywhere else in Afghanistan. The governing patriarchy was welcoming and surrounding us, and the Pashtun tribal code calls for unbridled hospitality to one’s guests. Additionally, we were there to present a gift: a new medical clinic. Certainly the word was passed long before we arrived that the Americans are to be welcomed and escorted safely to and from the village.

The minister explained in English that before we talked of the medical clinic, we would "of course follow the cultural customs," and that was when the blind muezzin across from me began chanting select verses of the Koran that nobody but the mullah seemed to understand as the performance was sung in Arabic. Following the religious formalities, a few of the Kuchi rose individually to make statements that not even a fellow Naval officer who is Afghan-American understood, as the Kuchis were speaking Pashtu and not the officer’s native Dari. So we simply waited out these monologues and the spirited ten-minute conversation between the minister and the Kuchis that followed; and at a point when the dialogue seemed to ebb a bit, the ministry representative sitting next to me leaned into my ear and said, “Oh, sir. They want us to build a 200-bed hospital here!” a project much larger than our plan for a medical clinic plus twenty-bed inpatient ward. Another five minutes of spirited Pashtu ensued, and my neighbor leaned over again and whispered “They say they have more than 100,000 people here now!” And after a few more minutes of Pashtu interlocution, even the minister who was leading the discussion looked nonplussed as he stopped the Afghan-to-Afghan dialogue and exclaimed in English to us, “They say they have not 100,000 people here, but more than 100,000 families!”

The typical Afghan family has around eight children, and the Kuchis themselves may be procreating at an even greater rate as one elder rose later in the meeting, came to the front of the room, and claimed (as I learned through the Afghan next to me) that he has two wives and twenty-six children and that the settlement needed a full-scale hospital to serve the burgeoning population. It took a several seconds for the native English speakers to get the translation that this man had fathered twenty-six offspring, and the Afghans present just looked at us with lascivious grins until a couple of Americans started clapping their hands in appreciation for this contemporary Abraham; and then everyone in the room starting cheering and laughing as that most fertile gentleman walked proudly back to his spot on the carpet. That individual Kuchi’s productivity notwithstanding, I found myself in disbelief that upwards of one million Kuchis had located themselves in that settlement. The entire population of Afghanistan is thought to be 30-35 million, and I doubted 1/30 of the entire population sat bivouacked outside the village walls.

Of course, the supposed settlement population was merely specious bargaining data for the Kuchis gathered around us. They wanted the biggest and best clinic they could get, and at one point their Parliamentarian and the mullah were literally leaning into the minister and demanding that he promise them today, in front of their fellow tribesmen, that he would build a 200-bed hospital for the settlement. The other Kuchis seemed well-schooled on the coercive power of an intimidating majority, as they stood (sometimes two or three simultaneously) and offered mandates of their own to supplement their leaders’ injunctions as the latter literally collared the minister, who at this point was perspiring noticeably.

I make no presumption to understand the intricacies and nuance of Afghan culture and interpersonal communication. In fact, the more time I spend here, the less often I am apt to even speculate on what is actually taking place before me as Afghans speak and smile and gesticulate among themselves. So I was only a bit shocked when, three minutes after the Kuchis seemed intent on strong-arming for themselves the Afghan equivalent of Beth Israel Hospital, the minister, looking somewhat less moist, turned to the us Americans with a triumphant grin and announced, “So, it is now concluded. We will build the original plan for the clinic and the twenty beds. Perhaps with the ability to expand later.”

Everyone seemed extremely pleased, and as I looked around the room every Kuchi had a smile on his face. Apparently no more words were needed, as cans of cold soda pop were distributed to everyone in the room and we all shut up so we could drink. I watched the muezzin quickly drain one can of Pepsi, and then a second, after his neighbor kindly opened the cans and gently placed them in the blind man’s hand.

Below is a short slide show with more photographs from the event.

The European Face of Afghanistan

2008-08-08T10:50:00.000-07:00

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

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

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

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

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

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

Afghan Army Physician Recruitment Strategy: A War with Pakistan

2008-08-03T20:50:00.000-07:00

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

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

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

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

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

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

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

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

Kandahar Police: Prosthetic limbs and eye makeup

2008-07-26T08:26:00.000-07:00

Photograph: Policemen and police recruits display
a short-lived semblance of order and discipline.

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 schrapnel lodged in their legs, arms and scalps.

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 sizeable 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.

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 Coumadin after heart valve replacement, and another current policemen in atrial fibrillation medicated with digoxin. (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.

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 Pashtuns (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 Pashtu) about their stomach pain, or headache, or immediate need for a vitamin injection (a very popular therapy in Afghanistan) or intravenous fluids.

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 discernible 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 Pashtu “Dookahn bundee! Dookahn bundee!” (“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.)

Many Pashtun 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 prevalent among Afghan males; but the Pashtuns darken their eyelashes in belief that the practice strengthens their eyesight. Or improves already weak vision. The darkened eye adnexa 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 Pashtun male maintains his darkened eyes no matter what he is wearing, even if he is sporting a police uniform.

I learned during my brief time in Kandahar that the Pashtuns, at least the men willing to join the police force, love to entertain and to be entertained. They laughed when I attempted to speak Pashtu to them (“Stan am Najibullah dee?” – “Your name is Najibullah?”) and shadow-boxed with the three police named Mohammed Ali (although I don’t think any of them were familiar with The Greatest of All Time). They joined me in preemptively shouting “Dookahn bundee!” 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 Pashtuns are the ethnic group from which the Taliban sprung.

Kandahar: Desert heat and the Taliban nearby

2008-07-24T19:45:00.001-07:00

Photograph: Main Avenue. Actually, the compound's only avenue.

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.

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.

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.

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.

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.

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.

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.

Photograph: Me atop OP Septic Tank.

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.

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.

Military Air Travel Part II: Tactical landings and other joys of the journey

2008-07-20T09:14:00.000-07:00

As a military aircraft approaches an airstrip in a combat zone, the pilot takes the plane through maneuvers collectively categorized as a “tactical landing.” The purpose of the intermittent acceleration and deceleration, sudden banking and very quick descent onto the runway is to minimize an enemy’s ability to lock onto the plane’s path and speed should the foe be planning anti-aircraft fire near the airport where the planes are low and vulnerable. The experience equates to landing in Denver from over the mountains in the west with a pilot who forgets he is no longer a stunt flier but instead is carrying a DC-10 full of paying passengers.

I recently withstood a tactical landing at Bagram Air Field in a C-130 packed with 70 other passengers, including an Air Force band whose extra pallet of musical equipment delayed our departure from Qatar while the bandmaster debated with the plane’s loadmaster over the ability to squeeze the horns and drums and amplifiers into plane’s cargo hold. While those two talked, we passengers stood in Qatari desert sun on a tarmac where the temperature was easily 135 degrees. (Instead of moving us back into the air-conditioned terminal to wait out the fate of the flutes and saxophones, the flight crew brought water to us as we huddled for shade under the wings of the aircraft. I poured my bottle over my head, and counted as the water evaporated from my skin, (sparse) hair and uniform in 3-4 minutes.)

The C-130 is designed to carry passengers, but it is not designed to carry passengers comfortably. The hull of the plane features four columns of heavy web seating, with paired columns facing each other. The space between the seating columns is so narrow that you have to alternately load passengers into the paired columns, and you end up with your legs intertwined with the passenger across from you. Also, the seating, like that of most military aircraft, seems designed to restrict blood circulation to the lower limbs. The air conditioning in the C-130 in Qatar didn’t begin operation until the plane had gained a considerable altitude, which left me wishing I had another bottle of water with which to douse myself -- until plane cooled so much that my perspiration-soaked uniform began to feel like a restrictive cool compress.

The C-130 features dismal airspeed (it is a propeller aircraft) and the flight path from Qatar to Afghanistan must skirt south significantly to avoid Iranian airspace. I’m tempted to write the Red Cross/Red Crescent to detail the discomfort military personnel experience on this route in hope that the relief organization might coax from Iran an humanitarian gesture permitting personnel transport planes to enter its airspace, and thus cutting significant time from the 5 ½ hour flight I endured.

The C-130 has a toilet located in the rear of the plane next to pallets of cargo, but it is a very simple commode with only a curtain for privacy. I’m not sure the best way to access the toilet if you are seated in the middle of a column of seating physically enmeshed with your fellow passengers, and I didn’t see anyone make for the toilet on this flight. Should you reach the C-130’s commode, you need not worry about anyone hearing you go about your business as the noise level in the passenger bay is significant enough to warrant ear protection.

After such a pleasant flight, a tactical landing serves to bring your travel to a memorable conclusion. The C-130 features several windows, portals really, situated five feet about the heads of seated passengers on both sides of the aircraft. During my recent landing at Bagram, our pilot several times banked the plane a complete 90 degrees, so that I could see the wing opposite me perpendicular to the (rapidly approaching) ground. The plane rocks and rolls enough that you cling to webbing (i.e. your seat) to keep upright. Once on the ground, the air conditioning usually cuts out well before you are able to depart the plane, thus coupling heat with any lingering nausea from the landing.

Of course, to burden yourself with the comforts of the C-130 is rewarding in that, de facto, you have actually boarded a military aircraft and are (hopefully) heading to your desired destination. For my recent flight out of Bagram en route to Qatar I left my base at 05:00 to make an 08:00 boarding brief at the airport, only to learn that my scheduled 09:00 flight had been delayed until 22:00. I felt fortunate that my flight, while later than expected, was at least leaving the same day. The final leg of my return journey to Kabul was originally scheduled to be a short flight from Bagram, but when I reported to the terminal at 04:00 I noticed that my flight remained on the departure board, but had been diverted to another city in Afghanistan. The diversion resulted in me staying at Bagram for two days waiting for an armored personnel carrier to drive me the thirty miles to Kabul. My transient billeting at Bagram was a lower bunk in a hanger that also housed temporarily an Army infantry battalion.

Military airports in combat zones always feature at least one large structure where passengers are often deceptively shunted to suffer under the illusion that they are about to board their aircraft. The military component of the Qatar airport has such a structure that I saw several times during transit to and from that desert Kingdom. It is a white building, roughly twenty feet wide and sixty feet long, with a dirty concrete foundation and a semi-permanent skin of a polymer material suitable for graffiti which restless passengers have filled from the floor to seven feet above with drawings of pin-up girls in skimpy Navy outfits, professional edicts (“Be polite, be professional, but be prepared to kill everyone you meet”), homophobic macho declarations (“I’m on a gunship, you’re a homo”), and descriptive stickers (“Kandahar rocks. There are many.”)

I “staged” in this building for six hours waiting for a flight from Qatar to Afghanistan. Several times I heard announcements that updated information on our flight would be passed in twenty minutes, only to hear sixty minutes later that no update was currently available. Once the ground crew marched us to the tarmac where we stood for thirty minutes staring at a large expanse of concrete devoid of airplanes before returning to the shelter to once again peruse the graffiti. Twice the ground crew dismissed us to the nearby flight kitchen that provides bag meals for travelers. Crew members typically expect passengers to wait together for hours enduring considerable discomfort in order that everyone on the flight manifest be ready to spring and seize the supposed three minute window allotted for boarding a plane after several hours of unexplained and ill-informed delay, so the fact that the crew released us from the staging area TWICE to gaggle over to the flight kitchen for sustenance assured me that no plane ready to transport us was anywhere near Qatari airspace.

The concrete floor of the building held what looked to be the collective filter catch of several hundred local vacuum cleaners, but I was lucky enough to find a piece of cardboard half my height and I slept on that for two hours before I heard, at 02:00, that my flight was cancelled (allegedly due to two successive mechanical failures) and that all passengers should return to the terminal for assignments to transient housing on the adjacent American base. After a bit of early morning travail with a terminal staff who seemed surprised that any passengers remained at the airport, and absolutely shocked that those same delayed passengers would request a bunk rather than bed down on the unimproved terminal floor, the other passengers and I boarded a bus and shortly found ourselves deposited at Quonset hut with a small staff who administered the temporary housing for the base … and who gave us the words you never want to hear at 03:00: “Everyone sign in here and then gather next door for your brief.”

All I wanted at that early hour (or so I thought at the time) was a bed of any type, as I was looking for a few hours of sleep before I returned to the airport at 08:30 (which was only 5 ½ hours away). I didn’t want the standard lodging brief, but instead a building number and a bunk assignment. I would take sheets and a pillow only if readily available. So, initially, I wasn’t too welcoming to the pleasant young woman who, after only a few minutes, entered the briefing room and asked, “Who here needs an alcohol ration card?”

Fatigue and dismay dissipated from the room as nearly all of us jumped from our chairs and bum-rushed that understandably stunned woman. Realize that in Afghanistan I am not allowed alcohol. During the R&R break I had just enjoyed, I was allotted three drinks daily. None of us expected an extended three-drink binge from the flight delay. We learned that the base bar closed at 04:00, forty-five minutes away, so we went from the briefing room (I’m not sure if I even stayed for the brief, or if I simply got my ration card and ran) to the linen office next door, then to our bunkhouse where we threw our bags and sheets before we scurried 200 years to the bar.

A friendly airman was tending the bar, and she informed us that we could buy only two drinks initially, but after a few minutes we could return for our third and final drink. Moreover, even though the bar closed at 04:00, we were welcome to take our accumulated cocktails and beer bottles outside to enjoy the sultry desert night at the seats and tables set under a huge, white, permanent awning that resembled an expansive, double-spired circus tent without side flaps and that is called, quite appropriately, The Bra.

Those drinks were refreshing. The early morning was beautiful. I drank and talked with friends as the desert sun rose and the base personnel starting to wake up and ambulate around us, unaware of how happy we were at that moment underneath The Bra.

Military Air Travel Part I: Sad and unusual cargo, and me, on the C-17

2008-07-19T01:22:00.000-07:00

Photograph: The C-17 Globemaster III aircraft. It might be loaded with Abrams tanks, 105 paratroopers, or 107,900 pounds of bottled water.

Military air travel within a theatre of combat is similar in several ways to civilian air travel undertaken anywhere else. To begin your journey, you report to an airport terminal replete with uncomfortable seats. You encounter restrictive baggage regulations. You are given flight numbers and departure times that have scant relevance to the eventual aircraft that, perhaps sometime in the future, will lift off the ground with you as passenger.

Military air transportation also offers two additional variables not typically encountered by civilians: You rarely know in advance on what type of aircraft you will be flying, nor do you know with what you will be traveling. I offer my recent flight from Afghanistan to Qatar as evidence. I reported to Bagram Air Field 30 miles north of my base in Kabul at 08:00 for my pre-flight brief to learn that my scheduled 09:00 departure had been delayed until 22:00. That night, I waited with a group of thirty other military personnel, headed with me on a four-day R&R pass to Qatar, until 23:30 to fill the jump seats on C-17 Globemaster III airplane already loaded with several 7000-pound spools of sheet metal, a single giant propeller twelve-feet in diameter, and the body of a Polish soldier killed the previous day in southern Afghanistan -- his remains now in a casket draped with the Polish flag, secured to the deck of the C-17, and on their way back to his family and his native land.

Photograph: Inner bay of the C-17. Notice the flag-draped casket of the Polish soldier in front of what surely must be one of the world's largest propellers.

The casket sat at the front of the C-17’s huge bay, between the passengers in the jump seats, and was the first thing I saw as I boarded the aircraft. The other passengers and I knew we would be traveling with the remains of the Polish soldier, as a gate attendant informed us before boarding that the casket would be on the flight along with a Polish escort. I give the US Air Force courtesy points for early notification that the accompanying cargo on this C-17 would include something different from the spare engine parts and tires which typically keep you company when aboard that aircraft. The attendant also asked us to please show respect t to the casket during the flight, a request I don’t think we required but certainly not inappropriate. You couldn’t forget about the dead soldier during the flight due to the casket’s position in the plane and the fact that you had to pass it to enter and exit the aircraft, and to get to the bathroom while aloft for five hours.

I had seen the casket before the flight. Bagram is the main airfield in Afghanistan, where many of the military killed in combat are loaded onto planes for flights back to their homes. When the bodies arrive at Bagram from elsewhere in Afghanistan, they proceed in open vehicles through a Fallen Comrade Ceremony, where ALL military personnel on base line the streets and salute the trucks carrying the caskets holding the dead. Even if a body arrives in the middle of the night, announcements over the loudspeakers rouse the sleeping military masses at the airfield and everyone puts on a uniform and lines the street. Bagram has a long runway, at least 1 ½ miles in length, and the base itself runs alongside this strip. During a Fallen Comrade Ceremony, the procession passes by 1-2 miles of military solemnly saluting from both sides of the street. I stood for the ceremony as I was waiting for my own flight, but was surprised to see a Polish honor guard and then a casket covered with a Polish flag drive by as I assumed the dead would be American. The announcement for this particular ceremony did not mention the nationality of the deceased, and it wouldn’t have mattered anyway as everyone participates for any coalition KIA; even though the overwhelming majority of military stationed at Bagram are Americans.

A little more information about the C-17 aircraft may help illuminate why it’s not really unexpected that, during travel to an R&R break away from a combat zone, military personnel might find themselves seated next to the remains of a KIA. The C-17 is a transport aircraft and its primary purpose is to carry cargo, not people. It’s huge, and can fly a 70-ton Abrams M1 tank in its belly. In fact, it can fly with up to 170,900 lbs of equipment. Along the long frame of the immense cargo bay run several dozen fold-down seats for passengers, who are usually passengers of opportunity, meaning that they get those seats and fly only if the cargo load and weight does not prohibit them from overloading the plane.

You also realize very quickly once inside the C-17 that the aircraft is not designed for human comfort. It does have a bathroom, but the jump seats seem designed to compress a passenger’s sciatic nerve. There are no windows in the plane, so you deduce the plane’s movement and speed by the sound and feel of the wheels rumbling and groaning under tremendous weight below you, and the sudden cut in speed felt thirty minutes or so before the plane lands. A crew of two airmen, typically, does announce overhead when the plane is about to depart for the runway, and sometimes they give you the projected duration of the flight; but otherwise you hear only a constant rush of empty air that, if you close your eyes, would lead you to swear you were housed inside an enormous vacuum cleaner.

A nice feature of the C-17 is the ability to leave your jump seat once at cruising altitude to stretch out on the metal floor of the plane. You can spot veteran C-17 passengers as they have blankets and pillows ready for the opportunity. Of course, that opportunity is often limited, as it was on my most recent flight, when several lengths of chain securing the 7000-pound spools of sheet metal ran from the middle of the plane to the base of my feet; and I almost tripped over them and fell into the giant propeller mid-way through the flight when the plane was dark, it was 02:00 on my personal diurnal clock, and I was half-asleep and trying to get to the bathroom.

An unusual week, even for Kabul

2008-07-15T01:51:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

The importance of name and place

2008-06-18T07:43:00.000-07:00

My surname Willy and hometown of Kokomo, Indiana rarely bestow upon me any kind of social advantage. Countless times I have given my name as “Willy” at a registration desk or government bureau only to have an annoyed functionary ask me to please voice my last name. Usually I explain quickly that Willy is my surname, but once I simply repeated “Willy” to the question and the clerk looked at me, puzzled, and inquired, “So your name is Willy Willy?” I guess that wouldn’t be so odd in Indiana, as I once had a basketball coach named Allen Wayne Allen.

My hometown of Kokomo also creates confusion as most people want to know why the Beach Boys sang about the place as a tropical oasis if the city sits in the fertile plain of north-central Indiana. There is no other place in the United States called Kokomo, and my hometown’s namesake is the legendary Chief Kokomo of the Miami Indians. Unlike the Beach Boys lyrics that equate my hometown with Bermuda and the Bahamas, the actual Kokomo is more similar to Muncie, Indiana and Peoria, Illinois.

I’m happy to report, however, that in Afghanistan the surname Willy has served me well by endearing me to many Afghans. A very common Afghan family name is W’Ali, reportedly derived from the name of the Prophet Mohammad’s cousin Ali. It’s so common, and so many Afghans have told me that I have a local family name, that I have begun introducing myself as Dr. W’Ali. I simply explain that I’m from America but that my father is Afghan; and I just happen to look and speak like my Germanic mother. So far, the Afghans have accepted this without question, and oftentimes welcome me back “home” to Afghanistan with an extra piece of na’an bread.

Unfortunately, Kokomo doesn’t mean much to most Afghans. They are not nearly as impressed with the name of my hometown as were most Kenyans several years ago when I traveled to Africa. Kenya has a number of tribes, and many Kenyans consider themselves primarily a member of their tribe and secondarily a citizen of the country. Typical tribal names are Kikuyu, Kalenjin, Kamba and Pokomo, so when Kenyans asked me about my tribe back home in Indiana and I told them I came from the Kokomo, they were mightily impressed. They also applauded the fact that my tribe was more than 50,000 strong, herded many cows in our fields, and had diversified ourselves economically by producing mass quantities of motor vehicle parts.

Afghan tribes include the Pashtun, Tajik, Hazara, and Uzbek. Regal names all, but none with the repetitive velar plosive articulation of Kokomo. So my tribal credentials haven’t assisted me much in Afghanistan. Also, Afghanistan has a long history of invaders coming from the west, north and east, and I find they are a bit more worldly than the Kenyans. The Afghans know that foreigners usually adhere to customs and beliefs very different from and oftentimes threatening to the local milieu. So I’m happy to simply introduce myself as Dr. W’Ali, and hope nobody asks me from what village my father hails.

On the Road ... in Kabul

2008-06-13T07:48:00.000-07:00

Last week I completed the instruction necessary to obtain a driver’s license for Afghanistan. The course took about 45 minutes. Since Afghanistan has no driving rules, no stoplights, no stop signs, no lane markers, no speed limits – there’s really no auto etiquette at all – there isn’t much to learn in the way of motor vehicle regulations. Instead, the class focuses on operating the electronic frequency jammer inside each US military vehicle, an essential piece of equipment as it (usually) blocks the viability of a remote control to detonate an improvised explosive device (IED) that could be planted along a convoy route. The real driving instruction is OJT – on-the-job training. You take to the streets of Kabul in an armored Suburban or Humvee and learn as you proceed.

Amongst the Americans I have met, two distinct schools of driving exist. The first school preaches that Americans “own” the roads here, that the threats to our safety come from insurgent Afghans hidden among the general population, and that all Afghan drivers and pedestrians need to clear the way for our convoys or risk impact with a speeding, armored vehicle that would simply rumble over most local automotives and certainly flatten any body it contacted. I don’t adhere to the tenets of this school and its dogma that aggressive, sometimes outrageous driving is the best way to guarantee that they make their destination without harm to themselves. (I do understand that, like most other military personnel in a war zone, they wish to return home with their limbs and sanity.)

The aforementioned school doesn’t seem to consider that the typical Afghan on the street might not like to see US military vehicles careening through the sovereign state of Afghanistan with reckless disregard for the children and other pedestrians who are forced to stay vigilant for our convoys. (This threatened population would include the innumerable burka-clad women walking the streets with what must be drastically reduced peripheral vision.) I don’t think aggressive driving assists in the “hearts and mind” campaign over here. I know that I would be a bit peeved if I encountered, in front of my home, a foreign Humvee on the sidewalk with its horn blaring as it attempted to navigate around a fruit cart pushed by a sixty year-old man.

Unfortunately, aggressive Americans are not the only drivers terrorizing the local population. Many Afghans are quite proficient in maneuvers that would have you arrested in Boston for attempted vehicular manslaughter should you attempt them. A local told me, when I suggested that my driving skills might enable me to work as a Kabul cabbie after completing my military obligation, that the essential attributes of an Afghan taxi driver are fearlessness, recklessness, and a total disregard for the well-being of others. When I asked him if he thought that most Afghans thought similarly of American drivers, he simply shrugged his shoulders and said, “You have strong vehicles, so you will be safe.”

I belong to the driving school that teaches crazed driving, moreso than an insurgent in a suicide vest or a roadside IED, is the factor most likely to dictate harm to ourselves and others while traveling in Kabul. Thankfully, the commanding general of my base agrees with that philosophy as well, as recently he instructed us to remember that Kabul is an urban environment; and that safe driving means we must move tactically and cautiously in our vehicles without endangering the local Afghans. Recently an Afghan child died after a NATO vehicle struck him on a busy Kabul street, and a small but vociferous group of Afghans picketed an American base near the incident to protest the death and the aggressive, dangerous driving that they claimed was responsible for the boy’s death.

This second school doesn’t preach passivity on the roads. Kabul drivers seem to believe that passivity equals weakness that deserves dishonor and ridicule. If you don’t continually push your vehicle forward on the streets of Kabul, you will find yourself enveloped by bicyclists, buses, bread carts and small herds of sheep.

Although many of the streets I travel feature sidewalks, a significant percentage of Afghans prefer to ambulate on the asphalt amongst the vehicular frenzy. None of the streets have traffic lines or marked turning lanes. Occasionally, a one-way route suddenly will produce oncoming vehicles due to a crumbled road or obstruction ahead. Busy intersections and traffic circles often feature a frantic policeman waving his arms and blowing a whistle, but drivers usually ignore him which renders the cop as just another obstruction to navigate around. The Kabul streets are filled with challenges to the primary tenet of tactical driving: Keep moving. A stationary vehicle is an easy target for someone looking to cause harm and induce mayhem.

Even the most courteous drivers must constantly nudge into packs of other vehicles blocking a route, or authoritatively enter a roundabout with a bit of speed and sound of horn. You cannot drive more than a few blocks without encountering families trying to cross a busy street, sometimes with their livestock; and thankfully both humans and animals here are adept at dodging traffic. Driving in Kabul is an elaborate, frenetic dance that involves dozens of sudden partners, and every day I learn a few more moves.

The European Way of War

2008-06-10T08:28:00.000-07:00

Not far from my base in Kabul sits the NATO compound that holds the International Security Assistance Forces, or ISAF. Although the commanding general of ISAF is American, most of the military personnel at the Kabul ISAF command headquarters are European. I visit the ISAF base at least once most weeks and I see Germans, French, Portugese, Poles, Croats, Czechs, Romanians, Italians, Turks … There seems to be an inordinate number of Macedonians. I’m not sure of the size of Macedonia’s army, but my guess is that about half of that small country’s armed forces are deployed to Kabul.

The reputation of ISAF among many American combat troops is not overly endearing, as evidenced by the different explanations for the acronym ISAF:

1. I sit, Americans fight.
2. I saw Americans fighting.
3. I sunbathe at FOBs. (FOB=forward operating base)
4. I suck at fighting.

The European idea of the mission in Afghanistan does seem to differ from ours. Weekly I meet with the my ISAF medical counterparts, and rarely have I heard them speak of any developmental initiatives they’ve undertaken in Afghanistan. They serve here for only four months, which barely gives them enough time to become familiar with the challenges of Afghanistan; and certainly not enough time to make any impact on healthcare. I heard a British colleague once scold my boss for venturing out to reach the Afghan population. “See these walls,” he said, pointing to the faux-fieldstone walls of the outdoor café that looked as if they were lifted from a grade school set for Hansel and Gretel. “Stay within these walls where you are safe and secure.”

I told my boss at that moment that I agreed, and I recommended we forego the return trip to our base in order to stay at the ISAF compound, drink beer and chase some of the cute Czech nurses we met earlier. “We’re getting out of here,” he replied. “The temptation’s too great at this place.”

It’s a different war at ISAF, many of us Americans like to exclaim as we schedule superfluous meetings with the Euros in order to return to their base which features real butter in the dining hall, Toblerone chocolate and Cuban cigars. Recently an American Navy physician joined the ISAF medical staff, and when I first met him he asked if he could assist on any of my projects as he was doing very little with the Euros. I remember his words as “You can’t get anything done here with all the coffee and tea breaks destroying the momentum of the day.”

The ISAF base has bars, restaurants, and a courtyard full of small groups of soldiers chatting, smoking and drinking. A volleyball court there seems always in use, as does a small soccer field. The Euro Cup began this week, and I would bet that most work comes to a stand-still during the soccer match broadcasts. Today a Czech colleague told me that he will watch a match late into the night, and tomorrow little will get done at the office what with fatigue and the need to endlessly dissect the highlights. I asked him how long people can talk about a game with a final score of 1-0, but I don’t think he understood my sarcasm.

I do enjoy the company of the Euros. One of their senior physicians, a Croat who appears to spend most of his time eating and smoking, tells delightful stories about his travels to America including a six-month stay in San Antonio when he was accosted at restaurants for not tipping the wait staff (he had no idea of the custom) and scolded by women for his boorish behavior. This Croat, after dinner, usually enjoys a cigarette or two or three with a few of the German physicians. I once jokingly asked him if he recommended smoking to his patients. “Of course,” he replied. “Smoking is protective. 30% of people in Europe die from smoking, which means you have a 70% chance of dying of something else. Your odds are better if you smoke.”

Not satisfied with that justification of his habit, he added that in Africa, a child’s chance of dying is greater than that of an adult European smoker. “The science is clear,” he said and offered my a Gauloise. I assured him that he could always find work with an American tobacco company serving as a medical authority and corporate apologist.

Case Study in Frustation: The Helipad Project

2008-06-06T07:56:00.001-07:00

This incompletely demolished building supposedly holds in a wall the unexploded grenade which gave the Afghan deconstruction workers a long weekend and the helipad project another delay.

A former girlfriend of mine described the beginning of our relationship as a series of “fits and starts:” My behavior would give her fits every time she attempted to start something meaningful. Development projects in Afghanistan usually follow a similar course, and I am the person frustrated. I offer the case of construction of the National Military Hospital (NMH) helipad in Kabul as an example.

The NMH is the tertiary care center for the Afghan Army’s hospital system, and a helipad to accommodate casualty evacuations from smaller regional Army hospitals and battle areas is a reasonable expectation. Utilization of the helipad necessitates helicopters, however, and the fledgling Afghan Air Corps has only a dozen or so of those, none of which are outfitted specifically for carrying casualties. Moreover, the Army has few if any medics who could actually accompany and support casualties on a flight; and even if trained medics were available they would not have the life-support equipment necessary for the job. The fact that Kabul sits at an elevation of 6000 feet also presents a big problem for casualty transport as a helicopter would have to climb even higher than Kabul itself to clear mountains around the city, and the altitude necessary would not behoove the state of a critically ill patient aloft in non-pressurized aircraft. So I don’t expect to see activity resembling the M*A*S*H intro anytime soon.

In fact, I might not see a helipad at all in the near future as controversy (as well as supposed unexploded ordnance discovered at the site) has stalled its construction. Several buildings stand on the site where the helipad will rest. A local firm procured the contract to level the buildings, but when crews arrived to begin the deconstruction project an Afghan general stopped them, claiming that the bricks, wood and metal from the buildings were property of the Army; and that he would supervise razing the structures with his own personnel. A few weeks before this confrontation, I attended a meeting where Afghan medical authorities requested a crane in order to assist with the helipad project. I thought that was strange, as I assumed the contractor would bring his own equipment to the job site. Only in retrospect did I realize that the general was planning then his own deconstruction project, an activity well outside the contract for the helipad as the language clearly gave the private firm possession of all scrap material from the buildings’ destruction. I’m not sure where the general instructed his men to transport the building material, but I would guess that, were he successful, the yard at his home would have resembled a second-hand lumber outlet.

In the past few days, the engineers and contracting officers seem to have quelled the contentious debate over ownership of the scrap material (by ruling in favor of the contractor). That does not mean, however, that the deconstruction/construction project is once again moving along, as work crews reported two days ago that they found an unexploded grenade in the walls of a building they were wrecking. Now work at the site is suspended until someone (who exactly I don’t know) comes to remove the ordnance. I’m suspicious that what they found was not an explosive at all, as the workers claimed they tore the top off the ordnance before recognizing it as a grenade. I don’t know very much about combat arms, but I think that ripping “the top” off a grenade either would leave it inert (as you removed the firing tab) or cause it to explode after a few seconds. Yesterday I toured the now-barricaded helipad site with one of my supervisors who wisely suggested that we explode the thing ourselves as that would not only destroy more of a building that’s coming down anyway, but also get the Afghans back to work on the project.

I’m calling this project a helipad, as that is the eventual purpose of what will in reality be a large concrete slab; but some of the contracting agents insist on calling it by its official name: overflow parking lot. The US military command funding the construction had not allocated money for a helipad in the budget for fiscal year 2008. Therefore, you cannot officially build a helipad in the year 2008. But a budget somewhere must have committed money to parking lots, because under that financial rubric the project received money; and now the helos, if they ever arrive to land, will technically alight on Parking Lot LZ, which will be distinctive for the large H painted in the middle of it. Hopefully, the few Afghans who own cars will not decide to park there, and no grass will grow at the edges of Parking Lot LZ, as I can imagine a helicopter approaching with a wounded soldier only to find a couple of 1985 Toyota Corollas blocking the middle of the slab and grazing sheep occupying the periphery.

The wisdom of the US federal budgeting process dictates that the fiscal year 2009 budget will include money for helipad construction, and my engineering colleagues informed me that next year the site will receive upgrades such as lighting and increased size. With nightly illumination, the helipad will be one of the few sections of the hospital actually designed and funded to operate 24 hours per day (if someone remembers to turn on the lights in the evening).

I am not trained in anything aerospace related, so I was intrigued last week when I met with officials from the local airport and Europeans from a neighboring NATO base and they showed me a satellite photograph of Kabul with a few circles drawn on it, circles that designated restricted Kabul airspace and which bisected the NMH campus and the site of the helipad. I got a bit nervous when they explained that the restricted space was to prevent aircraft from flying over, among other structures, the Afghan Presidential Palace. They assured me that the restricted space could be redrawn, especially in light of the military medical helipad construction, but that they would appreciate a copy of the site survey, surely conducted before selection of the landing site, which would outline approach patterns and possible flight obstacles and other things you apparently are supposed to study before selecting a site for a helipad. I assured them that I had absolutely no idea if a site survey had been done, but that I had seen the site and my layman’s evaluation was that the helicopters would be able to come in just fine as long as we kept the Corollas and livestock off what, technically, will be a parking lot.

Same place, different lives

2008-06-04T07:57:00.001-07:00

At least once a week I drive with a team through several villages on the outskirts of Kabul on our way to a clinic. In most of the villages, children will run alongside our Humvees waving their hands. At first I thought they merely were being friendly and were excited to see a convoy of armored vehicles pass by their homes. There was certainly an element of that in their behavior, I was told, but the children also know that sometimes we will throw bottled water or candy through the windows to them. Lately we have not been tossing anything as we want to discourage the children from coming too close to the vehicles. I’ve seen a few kids so close to the Humvees that, if they slipped, they would fall under a tire.

I often think how very different my life is from that of these Afghans even though I am physically close to them as drive through their villages. For security reason, we cannot stop and leave our Humvees to meet them. So the armor of the vehicles serves as quite a metaphor for the barrier between us.

The villages are mostly dusty settlements of mud-brick homes. My photographs of them are poor as I have to shoot through the dirty windows of our Humvees. I wrote the following poem recently after returning from a drive through the villages.

Separate

Our Humvee crawls over the cratered road
Of the village like an enormous beetle
Navigating a boulder-strewn field,
Laboring under its heavy, plated shell,
Its antennae prodding the air
For sound of distant trouble.
Dusty children skip alongside us
Each with one thumb pointed to the sky and
The other to the mouth,
Their smiles pleasant reflex sewn
In weeks past when we tossed bottles of fresh water
Out the windows to them until
They came too close,
When they ran and pounded our armored doors
So feebly I could barely hear impact
On the steel that kept us separate
As the Humvee, a tottering insect,
Rolled past them.
After that came the orders:
Nothing more to the children
To keep them back from us,
Safe in the cloud of dust
That follows our crawl past their homes,
That dirties them more and increases their thirst.

Many Afghans believe the US supports the Taliban

2008-06-01T09:10:00.000-07:00

It is a commonly held belief among ordinary Afghans the U.S. forces do not want peace and security in Afghanistan – and that in fact, American forces are supplying and supporting Taliban insurgents.
Kabul Times editorial, May 21, 2008

When I read the statement above, I didn’t know if I should be shocked and angry or simply bemused. I’m not sure of the reputation of the Kabul Times, a periodical that appears regularly on my base. One of my Afghan colleagues, for reasons I don’t understand, dismissed it as a publication of the mujahedeen; but I was very curious if in fact the common Afghan really believes that the US supports the Taliban. So I asked several Afghan friends with whom I work, and their polite yet earnest responses were that many of their countrypeople are suspicious that the US doesn’t want a lasting peace in Afghanistan, and they gave the following arguments as typical for supposed US support of the Taliban:

Why does the US let the Taliban hang around?

In 2001, US forces routed the Taliban from Kabul and most other regions of Afghanistan in less than two months. With that context, the Afghan mind posits: Why does the US now have trouble destroying small cells of insurgents positioned throughout the country? The answer: Because the US isn’t trying. The US is a victim of its own previous success, with the general Afghan public blithely unaware of the complexities and difficulties inherent in expunging organic groups of rebels who merely need to cross the border into Pakistan for sanctuary and training. Afghan disbelief of the true US intent – to rid Afghanistan completely of insurgents – is analogous to a patient’s dismissal of modern medicine with the argument that physicians are not interested in preventing the common cold even though they relish curing some cancers and transplanting organs.

Corrupt government: Perfected by Afghans, funded by Americans

A colleague of mine who is a respected physician in the Afghan Army was quite emphatic when he told me that the #1 enemy of the Afghan people is not the Taliban, but corruption; and especially corruption at the highest levels of government. Many Afghans resent their current leaders and ministers, many of whom fled Afghanistan when the Taliban took control of the country. These elites returned to Afghanistan and power due to American support – and money. The typical Afghan, who has seen little benefit from the billions of dollars of international aid sent to Afghanistan in the last seven years, apparently is easily convinced that the power elite of the country, seemingly beloved of the Westerners, has no incentive to alter the current state of affairs in Afghanistan as their graft of foreign aid is quite a lucrative undertaking; and the Western aid dollars might stop passing into Afghanistan and their own pockets should Afghanistan ever stabilize into a peaceful, secure state.

Western governments, exemplified by America as the US both politically and militarily has the most visible foreign profile in Afghanistan – indeed, many Afghans assume any Caucasian to be American – must know the corruption exists, reasons the typical Afghan, and yet they still support thieving Afghan officials who have no interest in truly reforming Afghanistan for the good of the common citizen; therefore, the Westerners (i.e. the Americans) must support an unstable Afghanistan, which means they support the newly resurgent Taliban.

The Afghan argument here proves itself a syllogistic fallacy at several junctures, but a philosophic analysis and repudiation of what many Afghans believe likely will not change their minds. History shows that emotion and belief are usually cruel victors over reason. What might change the Afghan mind, say my colleagues, is evidence that foreign aid is earmarked for the country’s development instead of the ministers’ bank accounts. “No one here wants to fight,” an Afghan physician told me. “Build a road for people, and they will be thankful and peaceful.” This from a man raised in Helmand, a province infamous for producing Taliban fighters.

The guys you want are just across the border in Pakistan. Why don’t you go get them?

The Afghan people know, as do the Pakistani people and the American government, that most Taliban and other willing insurgents ready to fight in Afghanistan are trained across the border in Pakistan. Pakistan historically has been the prime supporter of the Taliban. If the US truly wanted to rid Afghanistan of the Taliban and other insurgents, thinks the typical Afghan, it would destroy the bases it knows exist in the northwest territories of Pakistan. The US doesn’t do that, but instead maintains a (notably uneasy) alliance with Pakistan. And so the (illogical) deduction holds that the US supports the Taliban as does its ally Pakistan.

I’ve learned over my four months in Afghanistan that most people here harbor little-to-no fondness for Pakistan, as the Afghans believe (with some justification) that their neighbor’s goal is to keep Afghanistan poor and destabilized. So I got nowhere arguing to my colleagues that the US-Pakistan alliance had everything to do, initially, with removing the Taliban from Afghanistan. Nor did they cotton to my proposition that the US is overly taxed now fighting wars in two countries, and a third front just might send the military into an irreversible downward spiral.

I was relieved to hear from my colleagues that although many Afghans might believe the US condones the activities of the Taliban, they don’t think the US directly funds and supplies those insurgents. Instead, many Afghans site evidence that the British are the foreign force bolstering the Taliban with weapons, food and material. I’ll write more on that topic at a later date.

How NOT to improve the plight of the typical Afghan

2008-05-29T13:28:00.000-07:00

Yesterday I was returning from a project in a village just outside Kabul when our convoy of Humvees came to a stream that bisected the road. It’s not unusual when traveling the roads around Kabul for the path to truncate at a ridge or field or waterway where a causeway has yet to be built. The water at this particular obstacle was still and lie at the bottom of a channel that was no match for my Humvee or its driver: she simply slipped the machine into low gear and plowed through the muck and liquid. We sank tire-deep into the soft bed of the stream as we drove through it, and when water splashed over the Humvee our cab filled with the smell of sewage. The innards of our vehicle stayed dry, thankfully.

The village next to that sewage stream lacks much more than proper plumbing. Not immediately next to the sewage flow, but still far too close to it, children pumped water from a manual well. None of the streets of the village are paved and tremendous clouds of dust and dirt trailed our Humvees. Most of the homes and buildings are constructed of mud bricks. The needs of that village are exemplary of the needs of most Afghans, and the needs are basic: clean water, proper sanitation, decent housing and all the other public health measures and protections that the United States developed in the 19th and 20th centuries.

Occasionally my office will get proposals from organizations that don’t seem to recognize that simple projects -- not high-tech, complicated initiatives -- are the endeavors appropriate for assisting most Afghanistan. Although I’m sure these people mean well, their proposals are often laughable as they clearly have no understanding of the lack of physical infrastructure and socioeconomic support here that would conspire together to ensure their projects failed.

The latest proposal I read this week (shortly after driving through the river of raw sewage) called for an initiative to create an electronics laboratory in Kabul that would enable Afghans, especially those injured and maimed from mines and other weapons, to develop electronic devices, software and computer-controlled machines. The organization proposing this lab has a greater mission: to bridge the “digital divide” in poor communities and to improve the “technoliteracy” of populations deprived of the latest advances in technology. I see more than a few problems with the proposal.

The lack of technoliteracy is certainly an issue in Afghanistan, but the lack of basic literacy is a much greater problem. I think I knew how to read and write my native tongue before, in junior high school, I tackled the Basic programming language of the Radio Shack Tandy computer, and then moved on to master the remarkable Commodore 64. Perhaps we need to ensure a quality primary education for Afghan children, including the girls, before we worry about producing a generation of software designers here. I can also guarantee that initiatives to further train Afghans in skills that presuppose literacy and a rudimentary education will only further separate the privileged from the poor, disadvantaged and neglected. Afghan society is supremely hierarchical, with a few wealthy and educated folks controlling most of the economic resources, social power and educational opportunities. Development and assistance efforts need not completely ignore that segment of the population, as it is highly influential and typically a social conduit for foreigners to all else Afghan; but initiatives need to be structured so that the needy, which comprise about 99.9% of the population, are served.

The “digital divide” is another stark contrast between the have and have-nots in our world, and the chasm that surrounds the typical Afghan is quite shocking to most of us accustomed to computers and software and all the other elements of the digital revolution that keep us pecking at our keyboards instead of conversing with our friends and families. But the village kids who run alongside our vehicles with one hand outstretched and the other gesturing toward their mouths are not pleading for a laptop computer: They are asking for bottles of clean water that they know we keep in our vehicles at all times. I don’t presume to speak for the population here, but I think a priority for most Afghans would be for us to assist them in bridging the clean water divide before we address the digital divide.

After pondering the digital divide, I quickly drafted a list of other divides that I think trump the shortfall of digital technology in Afghanistan. I ranked the divides according to priority after I compiled them:

Top Afghan Divides
1. Nutrition Divide
2. Clean Water Divide
3. Literacy Divide
4. Sanitation Divide
5. Healthcare Divide
6. Viable Shelter Divide
7. Human Right Divide
8. Hygiene Divide
9. Living Wage Divide
10. Modern Utility Divide

94. Applied Technology Divide
110. Digital Divide
125. Wireless Internet Access Divide
133. Bluetooth Divide

Another quick thought on the specter of the digital divide in Afghanistan: Efforts to advance digital technology likely presuppose a constant supply of reliable electricity. I propose a drastic improvement in the power plant capabilities of this country before we worry about installing wireless internet service. If I were a politician, I would promise a reliable light bulb in every home.

Finally, I think any development initiative that provides electronic skills to Afghans must consider that more than a few insurgents in this country are eager to acquire the knowledge necessary to create sophisticated explosive devices that typically kill and injure Afghans, not foreigners, when detonated. Today a suicide bomber in Kabul drove his vehicle of charges into an armored American military SUV. The Americans in the vehicle survived with minor injuries, but four Afghans on the street near the explosion died and three others were injured. The Associated Press reported that children’s’ shoes were seen strewn about the site. Most Afghans want peace and a secure livelihood, but a laboratory serving a segment of the population interested in learning about homemade electronics runs the risk of educating the local equivalent of the guy who enrolled in flight school with no interest in lifting or landing an airplane, only controlling it once in flight; and he used that training to fly a jet into the World Trade Center.

Biblical plague strikes northwest Afghanistan

2008-05-19T10:32:00.000-07:00

I’m not a Biblical scholar or an historian of antiquity, but I find it pretty easy to imagine a string of natural disasters that overtook the Egyptians thousands of years ago and which, over time, became such powerful collective memories for the Jewish people that the recollections became Myth and eventually documented in the Book of Exodus as evidence of the variety of products available to Yahweh when He went looking for a can of whoop-ass to open up on populations gone astray.

The peoples of northwest Afghanistan are mostly ethnic Persians and Turks and not descendents of the ancient Egyptians, but lately they must be feeling that a pharaoh of their ilk somewhere has done something terrible to raise the ire of God as they are withstanding yet another plague of Biblical fame and severity: locusts. This insect infestation is nature’s latest sucker punch into the gut of a region that just endured a brutally cold winter and continues to suffer from drought. Afghan health officials also fear that much of the wheat in one of the poorest provinces, Gulran, may be contaminated with the toxic weed charmac whose seeds get mixed with the grain and induce a toxic liver syndrome especially deadly to people already chronically malnourished (a group quite prevalent in northwest Afghanistan.)

The swarms of locusts, which can number in the millions or even billions, can quickly devastate and denude thousands of acres of crops. Afghan authorities describe the current swarm as “unprecedented,” and are offering 15 lbs of wheat for every kilogram of dead locusts. So far, Afghans have killed more than 300 metric tons of the insects.

Locusts are usually solitary creatures and researchers have long wondered what provokes the insects to suddenly swarm together. I was also curious why recent accounts of large locust swarms arose from regions chronically devoid of much arable land and growing grain (e.g. northwest Afghanistan and northeast Kenya). If I were a locust and looking to group with a billion of my own kind for a feeding frenzy, I would swarm where the land is rich in crops. Observant scientists have proposed some explanations that revolve around topics also relevant to the Old Testament: sexual arousal and fratricide.

Academics at Oxford propose that locusts have sensitive hairs on their legs that when stroked stimulate gregarious behavior. I’m not kidding when I write that the scientists call these hairs the locust G-spot. No scientific publication has yet confirmed enhanced locust orgasm with G-spot stimulation or that a locust swarm is simply a hovering, mobile insect orgy. The main activity of the swarm, I thought, was eating; and the Oxford group did not theorize if increased locust libido underwent sublimation into ravenous hunger. A human example of that, I suppose, would be a dinner party where all the guests engaged in such a fervid bout of under-the-table calf-rubbing and thigh-massaging that, instead of peeling off in pairs to copulate, they all got up and as a group rushed to devour sequentially the contents of every other neighborhood kitchen.

University of Sydney scientists posit a theory somewhat akin to the Cain and Able story that also explains why the locusts often swarm in barren lands. These researchers contend that the insects begin swarming after vicious abdominal biting due to the lack of other suitable sustenance. The locusts aren’t necessarily jealous of one another, just damn hungry. Hungry enough to turn cannibalistic. Then a vicious cycle begins where each individual locust simultaneously flees from another predator locust while pursuing more same-species prey, and the swarm is on. These scientists found that a locust can live and fly swarm with most of its abdomen eviscerated, an impressive finding but information I find confusing as it seems that the evisceration would be the equivalent of locust gastric bypass surgery and reduce the appetite so much that the insect would simply drop from the pack to find solitude once again – and pray that dumping syndrome doesn’t set in.

Afghanistan's tallest man knows nothing about basketball

2008-05-11T08:39:00.000-07:00

Photograph: It’s not a cut-out figure. It’s Afghanistan’s tallest man standing next to me.

From a distance I saw him entering the hospital and the other Afghans, whose average height approximates that of Americans, looking at him in amazement. Two physicians who had taken photographs of him with their cell phones looked at me, recognized that I, too, was shocked by the man’s height, and said “The tallest man in Afghanistan!”

I did what any reasonable person would do: I rushed into the hospital to get a photograph with him. I found him just off the main lobby waiting for the elevator; and when I asked Abdul Mutalib by voice and gesticulation if he would pose with me for a photograph, he smiled and said yes. (I know very little about the Afghans as a people, but I am sure of this: They will abort any activity to be subject of a photograph, no matter what their height.) While Abdul’s companion took photographs with my camera, two dozen other Afghans gathered in front of us to marvel at Abdul’s height and take snap shots of us with their cell phones cameras.

Although Abdul speaks very limited English, I asked him the question that I’m sure was forefront in the minds of everyone gathered there: Do you play basketball? He looked puzzled by my inquiry, but even more confused when I pantomimed a jump shot. (Two young boys present both giggled, clearly unimpressed with my limited vertical leap.) Abdul did understand my Dari when I asked him his name, and he then told me, in broken English, that he was at the hospital for his feet which give him all kinds of problems. He then ducked into the elevator, which has a ceiling height of about six feet -- which was at least 1 ½ feet too low for Abdul. (I should have photographed Abdul as he folded himself into the elevator car, but I was distracted again by the two young boys who now where not only giggling at me, but pantomiming jump shots themselves. I must say, their form showed promise.)

Abdul impressed me immediately for two reasons. First, although he was extraordinarily tall, he had a symmetric physique. Some “giants” suffer from acromegaly, which is a disease of increased growth hormone and usually leaves the hands and facial bones disproportionately large. Think of the motivational speaker Anthony Robbins. Other extremely tall people sometimes have a condition called Marfan Syndrome that produces abnormally long, thin limbs. Speculation holds that Abraham Lincoln was a victim; and some people believe that Osama bin Laden has Marfan Syndrome. (I’ll not be journeying to the Afghan-Pakistan border on a medical mission to confirm that diagnosis.)

The second observation of Abdul that impressed me tremendously was the fit of his suit. Even though he towered more than seven feet tall, he was a rare Afghan picture of sartorial splendor. I haven’t noticed any Big & Tall shops in Afghanistan, but even those odd-sized specialists wouldn’t have anything in stock for Abdul. I’m upset that I didn’t get the name of Abdul’s tailor, as a nice suit of clothing for my 5’ 10’’ frame would be a simple project for a man able to convert an acre of wool gabardine into an impeccable outfit for a seven-footer.

An Afghan interpreter, after seeing the photograph above, recalled a television interview of Abdul. He is a farmer from southern Afghanistan. I would like to see Abdul’s tools, as he surely possesses the world’s longest garden hoe and spade shovel. The television show also proclaimed him the world’s second-tallest man. I’m not sure where the world’s tallest man resides, but I recommend he come to Afghanistan and visit Abdul’s tailor when he needs a new suit.

The dead get priority

2008-05-10T09:26:00.000-07:00

The American colonel did not think he was proposing anything radical when he explained the priority with which battlefield casualties are evacuated by helicopter to medical facilities for treatment. “Triage efforts,” he said, “determine the most serious casualties and those are designated for airlift out for treatment.” I’m sure his category of “serious casualty” meant a soldier who was wounded but still alive (although a dead soldier would assume the status of worst casualty imaginable.) The Afghan Army general present simply smiled, and then said something that stunned every American in the room. “Yes,” he said, “the wounded are important. But the dead, they are more important.”

Certainly, he continued, the bodies of the dead would receive priority for helicopter transportation to the nearest available facility so that they could be prepared for burial. Only then would resources be directed toward evacuating the wounded. A corollary to his argument, I suppose, would be that any wounded soldier who died while waiting for the corpses around him to be cleared from the triage area would assume a more urgent evacuation status upon expiring. The irony is that death, not injury, assures these soldiers the most rapid transport to available medical care.

The rational for the priority of the dead over the injured is the Islamic injunction that Muslims must be interred within 24 hours of death. I’m not sure of the spiritual consequences to the dead or responsible burial party should a corpse sit above ground for longer than a day, but the Afghans are taking no chances with their war dead. In fact, care for the dead is a such a priority that the hospitals allocate an inordinate amount of money and personnel, from the perspective of most Americans working here, to mortuary and burial affairs considering that the facilities are chronically short of basic supplies and equipment necessary for maintaining patients’ lives. Last week I attempted to procure from the head of a local hospital reliable data on the number of patients seen in the hospital and its local clinic. I also inquired about the hospital’s mortality rate. The physician had unreliable data for every category except the number of deaths last year in the hospital. “I know this number is correct” he told me. “I know it is correct as I provided every death with a casket. It’s a large item in my budget.”

Afghan priorities do not always mirror the priorities of the American medical personnel sent here to work with them. At the aforementioned hospital a huge reflecting pool (see photo to right) in front of the building has been refurbished, and it pains me to even speculate on the cost of that beautification project. Hospital authorities apparently insisted that the grounds of the complex be restored to their former state, and the restoration included planting beautiful roses, installing planters with flowers, and repairing the reflective pool. (The pool will certainly be the cleanest and most sanitary area of the hospital.) I applaud the landscaping, but I think I would have looked to improve the ICU or emergency department before I groomed the hospital lawn. Or I might have installed a proper, functioning medical waste incinerator as currently amputated limbs and all other discarded human tissue are simply buried in a remote corner of the hospital grounds. I'm not sure if Islamic law dictates that even extracted gall bladders and severed appendages deserve a quick burial. An Afghan at the hospital told me that human tissue is buried to keep it from the dogs.

But this isn’t my country, and it’s not my hospital. And the oftentimes befuddling projects and priorities I encounter here are not always disconcerting. Behold, as an example, the “jingle truck.” The so-called jingle-truck is a standard dump truck or heavy-duty hauling vehicle that nevertheless has an elaborate, beautiful paint job and ornate metal chains that hang from its carriage and chime as the truck moves. The truck in the photo was making a delivery on base right outside the door of my quarters. The driver, like every other Afghan I’ve met, was delighted to pose with his truck for a photograph; and he even insisted on “playing” the chime chains by stroking them with a plastic water bottle. On a recent trip through an industrial section of Kabul, I saw a line of at least two dozen jingle trucks apparently waiting to be hired. If I were looking to hire one of them for a job, I would have selected the most ornate jingle truck available.

Politically nuanced quote of the week

2008-05-06T06:26:00.000-07:00

I was away from Afghanistan for the Taliban.

-from the curriculum vitae of Brig. General Zahoor, Afghan National Army medical officer, to justify a gap from 1996-2002 in his professional chronology.

When your only food may kill you

2008-05-04T10:06:00.000-07:00

Please add contaminated grain as another tangible threat to innocent Afghans. Toxic wheat joins a list that already includes malnutrition, tuberculosis, malaria, civil warfare, female enslavement, Islamic extremism, dire poverty and drought.

In the northwest corner of Afghanistan, bordering Iran and Turkmenistan, sits the district of Gulran, where in 1974 an epidemic of liver disease struck the poorest families in several district villages. More than 20% of these villagers displayed clinical signs of liver toxicity, and the Afghan authorities determined the etiology as bread whose wheat was contaminated with the seeds of the charmac plant (Heliotropium). Charmac is a weed inadvertently harvested with the wheat, and the seeds contain pyrrolizidine alkaloids that inflict severe liver injury. The toxicity leads to a progressive, massive abdominal distention from fluid accumulation in the gut (ascites) as the liver degenerates over several months in a process somewhat similar to accelerated alcoholic cirrhosis.

Some villages in Gulran are suffering another epidemic of liver toxicity. New, dramatic cases of ascites began in November, 2007, again among some of Gulran’s most impoverished families. Many if not all of the victims are chronically malnourished and subsist on a diet of wheat bread that is occasionally supplemented with meat. (Very few fruits or vegetables grow in Gulran.) The cruel irony is that the little food these villagers have available might be killing them.

Health authorities transported several patients with severe disease to Indira Ghandi Hospital in Kabul for treatment. I visited these patients yesterday, and the first I saw were a pair of young siblings whose parents had both died recently from the disease. The next patient was a twelve year-old girl in such an advanced stage of illness that I would be surprised if she is still alive. She had a gaunt, weathered face that was absolutely skeletal, and I thought of the terrible newsreel footage depicting concentration camp victims liberated at the end of World War II. She looked ghastly. Thankfully, blankets covered her massive belly. Her limbs were so emaciated that the skin outlined the contour of her bones.

Initially I wanted to take a photograph of her, but I changed my mind quickly as I thought the attempt would be crass and vulgarly voyeuristic. Instead, I recalled another twelve year-old girl in Kenya whom I watched literally drown to death in a hospital bed over the course of a week due to congestive heart failure. Rheumatic heart disease had shredded her cardiac valves, and the damage had reduced her heart’s pumping capacity so much that blood collected in her lungs and saturated the pulmonary tissue, and eventually the mitigated oxygen exchange couldn’t sustain her. $5 worth of penicillin earlier in her life when she had a case of strep throat might prevented the cardiac disease. At least the Afghan girl had a bed of her own, as the Kenyan patients slept two-to-a-single-bed laying opposite directions on the mattress. If the Kenyan staff expected you to die within the next few hours, they would move your bedmate and place a screen around you, an effort that gave a bit of privacy in a crowded open ward and left the other patients less unnerved.

I haven’t cried over a sick patient since medical school, but I felt my eyes moisten when I saw that dying Afghan girl and the new orphans across the ward from her. The worst of the world’s cruelty seems reserved for the poor, young and defenseless. These children come from an agriculturally barren district, likely have a genetic predisposition for liver failure and suffered malnutrition before they even ate the contaminated wheat. Two of them were treated for tuberculosis the previous year. They are getting delayed but appropriate supportive care now in the Kabul, but they are so sick that they may die alone in the hospital away from any family members who have survived this latest epidemic. Mickey Mantle inexplicably popped to the top of the liver transplant list after years of pickling himself with booze, then he died only a few weeks later and took that precious donated organ into the ground with him. These kids have no prospects for such advanced medical treatment.

The two children in the photographs above are medically stable and the physicians think they might survive the liver toxicity. They still have dramatic abdominal swelling due to ascites. The boy seemed obtunded when we spoke with him. The girl was stationary but playful (look closely at the photograph and you can see that she is all belly under her dress), although at first afraid of a toy we gave her. In fact, all of the children were initially frightened by the stuffed animals we offered them, and one of the physicians told me they probably had never seen such a toy before.

Fast Friends and Close Colleagues: The Professor and Me

2008-05-01T08:36:00.000-07:00

Professor Lalzoi waits patiently for me to leave his office.

This week I visited the National Military Hospital’s ophthalmology department and met Professor Lalzoi, a 74 year-old Pashtun Afghan who claims he is the oldest physician at the facility. He speaks no English but is fluent in Russian as he trained for ophthalmology in the Soviet Union at least twice in the past. The Professor appeared to barely tolerate my presence. He’s a reticent man by nature, apparently, and when I tried to engage him on topics outside of medicine, such as the Afghan military and politics, he gave curt answers loaded with subtextual emphasis on the corrupt nature of many things Afghan and my unbelievable temerity for broaching the topics. He didn't exactly cotton to my suggestion that he run for president in the upcoming election, even when I reassured him that at least one 70-something candidate is de riguer in American presidential elections these days. I’m sure we will be good friends before my departure from Afghanistan.

A few patients arrived to break the uncomfortable silence between the Professor and me. The young boy in this photograph has strabismus, or crossed eyes, because he is far-sighted (hyperopic) and exerts such vigorous focusing power (accommodation) that one eye turns in. His father, an officer in the Afghan Army, explained that his son had lost his glasses. (Kids around the world are all the same.) The father then had his son come shake my hand. I know enough Dari to ask “What’s your name?” and the boy seemed so surprised when he heard Naame taan chees? from me that he couldn’t respond. (Then again, he might have understood nothing from my stab at Dari, leaving him to wonder what language I was speaking.) The father was happy to join us for a photograph, and then a technician put dilating drops in the boy’s eyes for the upcoming exam. That medication stings when it hits the eye, and most children I have treated start shrieking after the first drop and thrash about trying to stop the dose destined for the second eye. This boy simply put his head down and rubbed his eyes a bit. These Afghans are tough.

The Professor wanted to confirm the child’s spectacle prescription before writing an order for glasses, and when the boy’s eyes were dilated Prof performed a skiascopy examination in a dark room with a lamp using a few tools I have never seen before; but he was able to determine from the reflection of light off the boy’s retina the refractive error of the eyes and, thus, the proper prescription. I watched and thought the position of the boy with his father next to the lamp in that otherwise dark room might make for a great photograph. They both agreed to pose for me, and I took the photograph below.

The other two patients I saw with the Professor were both severe eye trauma cases. A boy who appeared to be nine years old earlier in the day had taken a pellet to his right eye after a friend of his fired a gun near his face. He had no pain in the eye, but no vision either. His cornea had a laceration visible upon simple inspection, and an x-ray showed a small metal object lodged in the socket behind his eye. He needed surgery later that morning to seal the eye, but it likely will never regain vision. His blindness is due to the negligent discharge of a firearm. Many Afghans have told me that thirty years ago very few people owned guns and Afghanistan was much safer than today, as it seems every family owns a weapon.

I also saw a soldier who had suffered severe facial and torso trauma from an explosive device that detonated near him recently. He was groaning and grimacing the entire examination (which was mercifully brief), but I was able to see that the iris of his right eye was incarcerated (i.e. stuck) in a laceration of his cornea. He, too, needed surgery to release the iris fibers and sew the eye shut. I went by the operating room when another ophthalmologist, Dr. Abdulmanan, was preparing the soldier for surgery. I’m not sure what type of anesthesia they use for eye surgery here, but he needed more of whatever he was getting as when I peeked into the operating room he was writhing on the table and kicking his feet into the air. Maybe he wasn’t fully sedated yet. I hope that was the case. There’s no way Dr. Abdulmanan could have done surgery with the soldier moving so much.

Thankfully, I had to leave the hospital about then. I find that I don’t really enjoy the company of patients in agony. That’s the milieu of other surgical specialties, such as orthopedics. You may know that the definition of an orthopedic surgeon is "someone who has a high tolerance for other people’s pain. "

Soporific delivery compensates for lecture's sparse humor

2008-04-30T08:30:00.000-07:00

Double-click the photograph to read the witty captions.

This week I gave an ophthalmology lecture at the National Military Hospital in Kabul, during which I silently recalled one definition of a professor: A person who talks during someone else’s sleep. The topic was glaucoma, a diagnosis of interest to very few people outside of ophthalmology. In fact, many ophthalmologists have little interest in the disease, so I was not surprised that a couple of staff physicians and a handful of medical students were dozing during the forty-minute presentation. I’ve written before of the easy and prolonged sleep I’ve enjoyed during my stay in Kabul, and evidently many Afghans are not immune to the sedative vapors that propel me into slumber. I was a little disappointed when I noticed that Dr. Abdulmanan, the only other ophthalmologist in the room, was asleep, but I doubt I had anything new for him. The lecture had begun with two ophthalmologists in attendance: the aforementioned Dr. Abdulmanan and Professor Lalzoi, the latter a seventy-four year physician who claimed he was the oldest faculty member at the hospital. But the Professor departed the lecture, after sitting in the front row looking extremely bored, five to ten minutes after I began. He later told me some sort of emergency compelled his departure, an excuse that is the Afghan medical equivalent of Saturday night hair washing.

I try to add humor to my lectures whenever possible, but what I thought would be laughable injunctions failed to elicit much mirth. Perhaps my idiomatic English didn’t translate well. For sure I thought I would get a chuckle when I showed a photograph of an Afghan hound, a show-breed canine famous for its long hair and distinguished profile; and also one of the more than forty breeds of dog predisposed to glaucoma. Instead of laughing at the veterinary allusion to a dog named for their country, the Afghans simply stared at the photograph, confused as to why the dog was called an Afghan hound as not a single person in the room had ever seen one or heard of the breed.

The audience also seemed confused when I stated that the prevalence of closed-angle glaucoma was unknown in Afghanistan, but since it was more common among Asians that Afghans with Asian blood were likely at increased risk for the disease. My translator himself seemed confused at this, and he turned and said to me, “We are all Asian.” When I informed him that I meant Chinese Asian, as in the bullied and widely despised Hazara Shiite minority of Afghanistan, he simply nodded his head vigorously and told the audience something that provoked them to slightly gasp in unison and then discuss briefly with their neighbors what I could only imagine was their perceived luck at being born Pashtun or Uzbek or Tajik.

I was able to elicit group laughter during the question-and-answer session when a nurse asked what he could do to treat his near-sightedness (an issue, by the way, that has nothing to do with glaucoma). I told him that no good, scientifically proven prevention treatments exist; but that, in America, some people believe that a diet heavy in carrots improves vision, the proof being that you never see a rabbit wearing glasses. Even after translation, that quip had the entire crowd chuckling.

Taliban remain a disruptive force in Kabul

2008-04-28T07:03:00.000-07:00

April 27 is the Victory Day holiday when Afghans celebrate their liberation from communist rule. A military parade yesterday at the main stadium in Kabul was supposed to highlight the national celebration, but instead an attack by the Taliban disrupted the event. Three Afghans died in the rifle and explosives barrage, including a ten-year old boy. Several others suffered wounds. It’s unclear if President Hamid Karzai was the target of the attack, as he was forefront on the main reviewing stand when the attack took place, along with many other Afghan leaders and foreign diplomats; but those men were unharmed. If the Taliban were aiming for Karzai or the main stage, then they are very poor shots. If they simply wanted to disrupt the event to illustrate their ability to infiltrate the security of Afghan defense forces, then they accomplished their goal.

I knew several people who attended the event. The day prior, I asked around for an official invitation for myself, but I didn’t inquire very earnestly about attending the celebration as many people suspected the Taliban would try to disrupt the parade; and usually the increased threat that insurgents will target a route or gathering prompts the US military to declare that site off-limits to all of us. First-hand reports I received from attendees confirmed news reports that considerable confusion surrounded the attack initially. Small arms fire errupted across the parade ground in front of the reviewing stand just as a twenty-one gun salute began during a rendition of the Afghan national anthem. A friend in another bleacher section told me he knew something started to go wrong, but he wasn’t sure what, when he heard people yelling to get down and then his section of US military guests, all of whom had been disarmed before they entered the bleachers, cleared the area quickly and hurried back to their vehicles and exited the stadium.

He recalled that most Afghans around him, while well aware that an attack was taking place, were amazingly calm. People were exiting at a brisk pace, but not running or panicked. An Afghan in front of him smoked a cigarette as he walked out of the stadium. Below is a link to a CNN video of the event that is remarkable for the nonchalance exhibited by the Afghan leaders and dignitaries who shared the stage with President Karzai, most of whom simply sat down once the attack began and appeared content to wait out the action in their chairs. The majority of Afghans seated to the lower right of the primary dias, where gunshots appear to hit at least one man in the front row, didn’t flee either. A few of them actually stood up and pointed to the direction of the gunfire. I don’t know if these guys are warlords and accustomed to small arms fire; or believers that, inshallah, they would survive this nuisance just as they had survived the Taliban before. All I know is that I was mightily impressed with their composure, and now that I’ve learned just a bit about the Afghan temperament and their customs, I would bet that if the skirmish lasted more than a few minutes they would have demanded that tea be served while they observed the gunfire below them.

CNN video of event: http://www.cnn.com/video/?/video/world/2008/04/27/coghlan.afghan.beep.cnn

Unaware of the disruption at the parade taking place less than two miles from my secure base, I was in the basement of the Post Exchange shop searching for an electrical adapter for my laptop computer when a store employee started yelling for everyone to clear the building. It was approximately 10 am and, I thought, fairly early for the shop to be closing, even on an Afghan holiday. After I climbed the stairs and proceeded to the door, I heard the base alarm blaring and people scurrying in every direction. I hadn’t heard the alarm before, but I knew it signaled either an actual attack or an attack drill; and either way I needed to get myself to the nearest mortar shelter. I ran by a military policeman ten yards outside the shop door who was yelling “This is NOT a drill! This is NOT a drill!” I picked up my speed after hearing that, and was in a mortar shelter in about three seconds.

The shelters are long, rectangular boxes of thick concrete with benches that seat twenty to thirty people seated back-to-back. Once inside, I heard an announcement over the base intercom reporting that this was indeed a drill, leaving me confused. A contractor with a cell phone called a buddy of his who was attending the parade and we then learned that an attack of some sort had disrupted the event. As more people streamed into the bunker, I heard rumors of a US convoy encountering an IED nearby and that a multi-national base very near ours was taking mortar fire. At this point, I was more curious than nervous, and I sat waiting for either an explosion or the “all clear” call. Thankfully, after fifteen minutes we got the announcement that we were safe to leave the shelters.

Quality shampoo serves as hard currency

2008-04-25T07:50:00.000-07:00

Every Friday Afghan merchants gather at a secure section on the perimeter of my base for a bazaar that offers a variety of wares: wool carpets, antique rifles, tailored clothing, marble flatware, Afghan hats, bootleg DVDs of American movies, etc. Amahkbaru sells pistol holsters and protective vests at his stall. I met him the week I arrived in Kabul when I was searching for a holster better suited for my body armor than the Army-issue item I received. During the price negotiation segment of that encounter (“My friend, $30 is special price and only for you!”), Amahkbaru let fly that he has five children and he would trade anything in his stall for a bottle of good American shampoo. (non sequitur you say? Perhaps. But Afghans often employ language and reason a bit differently from what the Western mind accepts.) He claimed that only Chinese-produced hair care products are available to most Afghans, and then he added what I believe where both Dari and Pashtu expletives as a verbal rating of the quality of those Chinese toiletries.

You will notice in the photograph that Amahkbaru has a beautiful head of hair, full of curls and bounce. I could not let him suffer any further ignominy due to dirty limp locks, so I rushed to the base PX, purchased a bottle of Pert shampoo for $3, and then traded it for a $15 holster. I tried to explain to Amahkbaru that Pert is shampoo plus conditioner and perhaps worthy of two holsters per bottle, but I’m not sure he understands the product’s double-action. I got only one holster. Regardless, he was thrilled with the transaction, as was I. I now visit with him weekly at the bazaars and his hair looks terrific. (Also, he reports that his children are doing well.)

Before you draft your email berating me for taking advantage of Amahkbaru with the exchange, I would like to emphasize that these Afghan merchants are crafty fellows and would NEVER make a trade or sale if they suspected they were not coming away with a profitable deal. The items in Amahkbaru’s stall are over-priced and he knows it. He also knows that most Americans will not barter for 30 minutes for a $3 reduction in price. Amahkbaru clearly values American shampoo as several of my friends, on my advice, have swapped bottles for holsters. In fact, two weeks ago I saw that he had at least three bottles of the stuff stashed underneath his stall, and I asked him why he was stockpiling. “Save for the future,” he said,”and my wife now want the shampoo before even the dollar when I am home from business.” No non sequitur there.

A bit more about Chinese-manufactured toiletries

I have heard several Afghans offer unsolicited commentary on the substandard quality of most Chinese products. Many futurists predict that the next 100 years will be the “Asian century” led by China as that country of 1.3 billion people will leverage its population and resources to become an economic superpower. But I have some (unsolicited) marketing advice for the whole of Chinese industry: You might want to implement some quality control. The future doesn’t bode well for you if low-income people in developing countries shun your (markedly inferior) products. I would imagine that many Chinese themselves are avoiding Chinese products. A Malaysian Chinese friend of mine recently told me that he avoids purchasing anything made in China, and that he resents the reactive "smear campaign" against honest, hard-working Chinese people worldwide that these cheap exports promote. People around the world, both rich and poor, are beginning to prove that a low price and availability do not necessarily stoke a desire to purchase. Add to that recent media coverage of potentially harmful Chinese exports such as toys doused with lead-soaked paint, incendiary batteries, tainted pet food and structurally unsound bicycle frames, and you get the impression that the label “Made in China” is becoming the standard for “dangerous and defective.”

Many Afghans believe that Chinese companies and plants are able to manufacture quality items, but that international business executives simply choose to dump inferior products in Afghanistan as they consider the Afghans either too unsophisticated to recognize the low quality or too desperate to clamor for anything better. Also, the typical Afghan has very limited spending power and considers a simple bar of soap a luxury item, no matter what the quality and price. Chinese know-how and reputation also withstood a public beating here recently when a building that a Chinese firm was refurbishing suddenly collapsed, killing more than a dozen Afghan workers. The firm and/or the Chinese government are compensating for the tragedy by building a brand new hospital in Kabul, a generous and thoughtful contribution; but I wonder how many Afghans will be comfortable heading there for medical care once the facility is finished?

Where’s my stuff made?

The Afghans and their complaints about Chinese toiletries prompted me to investigate the origin of my own personal hygiene products. Currently I have no gripe with the performance of my Edge Pro Gel Vitamin Enriched Sensitive Skin shaving cream or Axe Stimulating Guava and Volcanic Stone Extract shower gel, but I encountered significant difficulty when I tried to determine the locations of the production plants. Not one of my toiletries stated on the label the product’s place of origin. Several included the product’s US distributor’s name, which I found very suspicious as the implication is that Desenex foot powder and Colgate toothpaste are imported into the US from some undisclosed location. Two products listed websites for reference, so I reviewed company information on Listerine and the aforementioned Axe body gel to find that those sites, too, failed to identify manufacturing sites. (I also read nothing on the benefit of cleaning your body with fruit extract and rocks belched from the Earth in a volcanic explosion.) I was ready to contact the Food and Drug Administration to inquire about regulations for disclosure on US products until I found, in a self-directed internet search, that almost all Listerine is produced in Pennsylvania.

I’m not sure why Pfizer, the manufacturer of Listerine, doesn’t highlight the fact that its mouthwash is made in the USA. I haven’t heard anything negative about Pennsylvania exports recently; and if the Democratic primary candidates can be believed, the people of the Keystone State are some of the most-hard working and honest folks around. Real solid citizens. Listerine is pretty much synonymous with clean fresh breath. Why wouldn’t Pfizer want the public speaking of Pennsylvania mouthwash just as they refer to German engineering and French cuisine?

Perhaps a few of my bathroom products are made in China. If so, I give a segment of Chinese manufacturing high marks for quality and consistent performance. My grade would be even higher if I could find Kung Pao-flavored toothpaste and Sweet and Sour dental floss. The Chinese certainly produce quality food. Even the neutered Chinese entrees typically found in American restaurants taste pretty good, if only faintly similar to the original. If China can lift its other, newer exports to the same standard, it just might end the 21st Century with another dynasty.

A surprisingly simple way to lose weight

2008-04-23T09:44:00.001-07:00

Let me be frank: I can stand to lose 25 lbs. That would drop my Body Mass Index below the obese range and lower my blood pressure a few points. I’m happy to report that I have lost some weight. (I’m five to seven pounds lighter, the operative variable being the number of chicken wings consumed the dinner prior to stepping on the scales.) Unfortunately, I doubt the weight loss is linked to healthy alterations in my lifestyle. I wrote last week about the sedative properties of my environment that have me sleeping 8+ hours nightly and prevent me most days from rising early for exercise before work. Late morning hunger and afternoon fatigue then rule out a gym visit later in the day. In addition, the dining facility here features every meal several entrees plus a buffet line of hamburgers, chicken tenders, french fries, onion rings and hot wings; and I’ve discovered that increased sleep unleashes a powerful appetite once consciousness takes over.

The only way I can explain my weight loss is this: I no longer stop at Carl’s Jr. on my way to work for a breakfast hamburger, hash brown nuggets and a Coke. The Breakfast Burger is a charbroiled all-beef patty, fried egg, crisp bacon, American cheese, hash brown nuggets and ketchup on a sesame seed bun. Living in San Diego County and frequenting the drive-thru at Carl’s Jr. most days of the week, I was always confused why the Breakfast Burger featured the hash brown nuggets smashed within the bun of the sandwich as the Value Meal comes with a side order of those crispy golden nickels. The burger certainly didn’t need the deep-fried potatoes for extra nutritional value: the sandwich provides 830 calories and 47 grams of fat.

Simple math illustrates my contention that I’m losing weight by simply eliminating the Carl’s Jr. Breakfast Burger from my diet. If I ate 300 of the burgers last year (a conservative estimate), then the sandwich accounted for 24,900 calories ingested. A pound of fat stores approximately 3500 calories. Therefore, eliminating the (delicious and addictive) Breakfast Burger from my diet equates to (24,900 ÷ 3500) dropping 71 pounds! And that doesn’t even include the calories I miss from forfeiting 300 side orders of hash brown nuggets. Realize I have to eat something first thing in the morning, but imagine that I consume a decent breakfast of 500 calories daily. Again, simple arithmetic shows that such a (surely boring and unappetizing) meal equates, over 300 days, to 43 pounds, or 28 fewer pounds than the (delightful) Breakfast Burger breakfast. I might meet my weight loss goal simply by avoiding Carl’s Jr., which thankfully has no franchising plans for Kabul.

Kabul Medical University students clamoring for ophthalmology lectures!

2008-04-20T08:42:00.000-07:00

Beware owners of this breed, the Afghan hound: Your animal is predisposed to glaucoma and should have a complete eye exam from a veterinarian (not an ophthalmologist).

The efforts of the Navy medical mentoring team at the National Military Hospital are inspiring the medical students from Kabul Medical University who rotate through the medical center for clinical instruction. After a recent trauma care course presented by the Navy team, the several dozen medical students presented the course director with a list of topics they would like addressed in a lecture series. I was shocked to see that the twenty-three proposed lectures included two involving the eye: glaucoma and blindness. I’m accustomed to seeing lists of “essential” medical topics include well-worn issues such as sepsis, cardiac artery disease and gastroenterological dysfunction, but not eye problems.

My experience is that most medical students know very little and care even less about the eye, and that medical schools reinforce the negligence by giving scant instruction in ophthalmology during core courses. You would think that the phrase “life, limb and eyesight” would prompt a little more attention to vision. I cannot remember thinking much about the eye while I was in medical school, except for the day in the anatomy lab when we cut open cow eyes to peek inside. I can’t even recall a lecture on eye diseases and ophthalmic treatments. During our physical examination course I did learn the basic eye exam, although I didn’t really understand everything I was doing; and I remember an emergency medicine resident emphasizing to me that a patient’s visual acuity is measured separately for each eye at the Snellen chart (you know, the sheet of paper on the wall with the big black E).

I doubt most people could define optician vs. optometrist vs. ophthalmologist. Many patients of mine have commented that is must be wonderful to be able to do my work with only a bachelor’s degree. I’ve encountered nurse practitioners and even physicians who have no idea that ophthalmologists handle severe medical problems with the eye and perform surgery. What people presume about ophthalmologists these days is that we all spend our days performing LASIK surgery and making $1 million annually.

Even though the practice of ophthalmology in the US might suffer from the disinterest and confusion of the greater medical establishment, its status in no way compares to the lack of attention to eye maladies in Afghanistan. I attempted an internet search for information on glaucoma in Afghanistan, and found only two articles. I wasn’t investigating a rare disease such as kuru or Sanfilippo mucopolysaccaridosis. Glaucoma is the second leading cause of blindness worldwide. The two articles were simple surveys, valuable but limited in scope. In contrast, I was able to find dozens of internet resources for glaucoma in the Afghan hound, a beautiful long-haired animal that apparently is one of the more than forty canine breeds predisposed to developing glaucoma. I may write the American Kennel Club and try to shame it into a donation for ophthalmic research in the homeland of that distinctive champion dog.

You are in Afghanistan. You are feeling very, very sleepy...

2008-04-14T07:21:00.000-07:00

A deployment to Afghanistan might be a treatment for anyone who suffers from insomnia. I usually sleep pretty well myself, no matter what my location or state of mind, but my slumber in Kabul challenges that of a medicated ICU patient. I could have napped for an hour that afternoon or quaffed a Coca Cola immediately before turning down the sheets, but I will still sleep through the night. Yesterday is exemplary: I had a headache and so went under the covers at 8 pm, thinking if I woke up very early the next morning I would simply role out of bed and meander to my office to watch the major league baseball games that the Armed Forces Network was televising live. The early morning line-up was the Padres-Dodgers game followed by the Yankees-Red Sox. But instead of watching baseball, I struggled to make breakfast after logging eleven hours unconscious.

Afghanistan is a major producer of opium, and I theorized soon after arriving here (and discovering that I could easily spend half of this deployment face down on a pillow) that perhaps a narcotic dust lingers in the Kabul air, providing me a gentle, constant sedation. The opium is grown in the southern part of the country, however, the area from which the Taliban emerged and currently the region with the most fighting between the Taliban and NATO forces. So instead of producing a population of listless Lotus eaters, the opium region here has bred just the opposite. The likelihood is that something other than a ubiquitous narcotic cloud explains my fatigue.

Boredom, I think, is the etiologic factor that best explains my impressive slumber. Although my base is one of the most developed American facilities in Afghanistan, there isn’t much to do here. The compound is a walled, heavily fortified and guarded three-square-block area in the Wazir Ahkbar Khan neighborhood of Kabul (famous as the setting for the novel The Kite Runner), but I am restricted from leaving the base unless I am on official business and part of an armored vehicle convoy. I do have several sites that I must visit regularly for projects, including the National Military Hospital and the Ministry of Public Health, but both of those buildings are a very short drive and the trips don’t allow me to see much of the city. Most of the day I spend on the base, which does offer a gym, a small coffee house, a pizza restaurant and a few shops. I have internet access in my room (although I pay myself for the service). Meals are provided for me, as is a laundry service. The “library” is an overheated basement room with shelves of Louis L’Amour and detective novels. (I spent an entire afternoon searching for a history of Afghanistan, which is how I discovered the library. I’ve yet to find the history tome.) So I have pretty much everything I need, but I don’t have much to truly enjoy. And when I don't have much to enjoy, I feel bored. And when I feel bored, I get tired. And when I get tired...

A few blocks away sits the International Security Assistance Force (ISAF) base, the headquarters for NATO troops in the country. Many different European countries have forces stationed there, and they play by different rules when they go to war. First, many Americans think that the Europeans avoid combat roles. I’m not sure if that is really true, but more than a few people have told me that the acronym ISAF is short for “I Sit, Americans Fight.” Also, the Euros are somehow are able to afford a superior food service. The only complaint I have with the American food contractor, Kellogg, Brown and Root (KBR), is that the food KBR provided in Kuwait was better than what’s served here. For example, KBR Afghanistan forgot to import the endless dessert bar featured in Kuwait. But the NATO force food comes from a company called Supreme, and supreme it is with a cheese bar, hearty bread selection, butter and espresso machine at every meal. I can eat at either base, and at least one day a week my colleagues and I make business for ourselves at the ISAF base somewhere near lunchtime so that we can enjoy the European fare.

The Euros also allow their soldiers alcohol (it’s a dry deployment for us Americans), and their base has a bar and beer garden that has faux field stone walls and a wooden fence that simulates Bavaria, I assume. Shops on the ISAF base sell Cuban cigars (which are contraband in the US) and nice European chocolates and candies. The PX on my base has Kit Kat bars and stale Pop Tarts.

Again, compared to the quarters of many if not most Americans currently stationed in Afghanistan, I am living in luxury. Recently I visited a small base just outside of Kabul and literally threw a stone the length of the compound. At the regional hospitals in some of the smaller Afghan cities, my colleagues live on the medical complex grounds and wander virtually nowhere else the entire 6-12 months they work there. Kabul itself is relatively quiet and no mortar or artillery fire disturbs the night. So I will continue to sleep long and peaceful hours, inshallah.

The Great Massoud: The Lion of Panjshir, Hero of Afghanistan

2008-04-09T07:45:00.000-07:00

Photographs: The National Miltary Hospital in Kabul, yet another marvel of Soviet architecture. Clothing hangs out to dry on the Massoud Monument. Another view of Massoud Circle in Kabul. Massoud in the hat he made even more famous.

The National Military Hospital (NMH) of Afghanistan is a paragon of Eastern Block architecture built by the Soviet Union for Afghanistan in the mid-60s. The former USSR’s policies in that decade were more benevolent than in the seventies, when the then second super power decided to create its own Vietnam by invading Afghanistan in 1979 to support (i.e. control) the ruling Afghan communist party. Rumor in Kabul holds that the Soviets then used the basement of the NMH to torture select members of the local populace. A few years ago when US engineers inspected the facility, they reportedly found skeletons in the tunnels that run between NMH and other buildings on the hospital grounds. No one is sure if the remains are simply from a forgotten morgue, or the detritus of man’s indignity to man. I’m still waiting for a tour of these supposed catacombs, but every person I’ve asked to take me down there replies “It’s scary” and abruptly changes the topic.

The same engineers who assessed the building's functionality and soundness recommended that it be razed. The US has constructed new hospitals for the Afghan Army in four major cities around the country, and the NMH was judged to be so wanting for repairs and improvements that a replacement structure would be more economical than renovation. It’s the same argument that professional sports team owners use to coax (i.e. browbeat) municipalities to fund new stadiums, although in the case of NMH the paucity of luxury boxes was never an issue and it’s no stretch to claim that a new hospital might actually benefit the community that surrounds it. The Afghans, however, would have no part of NMH’s destruction, as it once was the operating base of the late Ahmed Shah Massoud, a National Hero of Afghanistan.

Massoud was an ethnic Tajik and one of the mujahedeen military commanders most responsible for the ouster of the Soviets from Afghanistan in 1989. He then joined with other commanders to form the Northern Alliance to fight the Taliban, who were vying for control of the country after 1994. His nickname was The Lion of Panjshir, as he hailed from the Panjshir Valley northeast of Kabul. (Panj is Dari for the number five, and shir means valley, so the moniker translates, literally, as the Lion of the Five Lions.)

So Massoud fought the Soviets, and he fought the Taliban; but history shows that a righteous military commander in Afghanistan always has at least one more warlord or lunatic group to subdue before total victory is his, and in 1993 Massoud found himself in a battle for Kabul with Gulbuddin Hekmatyar, a very nasty figure infamous for fickle allegiance and a well-deserved spot on the USA’s list of international terrorists after he tried to overthrow the current government of Afghanistan in 2003. Hekmatyar was also known for wantonly targeting citizens in his frequent bombardments of Kabul, and during the 1993 battle for the city Massoud led his troops and called for fire against Hekmatyar from the roof of the NMH.

Two days before America’s 9/11, on September 9, 2001, Massoud died when a pair of alleged al Quaeda operatives posing as Belgian journalists detonated a bomb during an interview with the commander. Most citizens of Kabul revere Massoud, and the current military reportedly rebuffed any suggestion that the NMH, Massoud’s former base, should be destroyed. Afghanistan has no registry of historic places, but if it did the NMH might be one of the earliest buildings with a bronze plaque. Or maybe something was lost in translation between the Americans and Afghans as they negotiated the fate of the NMH building, as at least two doctors there have told me that they favored a spanking new facility as long as a proper memorial were built in honor of Massoud. After all, they claimed, the Soviets built the NMH and they aren’t remembered fondly by the Afghans.

Massoud made even more famous the rolled wool hat that has long been an international symbol of Afghanistan and in the past has been called a pakol, or a Chitrali hat or Nuristani hat for the regions where the style evolved. Most Kabul citizens now call it a Massoud hat.

The traffic circle nearest the hospital boasts the name of and a monument to Massoud. The first time I saw it, a man was hanging wet laundry to dry on the wires circling the upper deck of the monument. The scene reminded me of the first time I visited the main temple of Angkor Wat and saw Cambodian cattle tied to the stone pillars and grazing on the grass surrounding the country’s most prized historic landmark. But Massoud was a man of the people, famous for retreating from Kabul to save its citizens from further torment of war, so I’m sure he wouldn’t begrudge that Afghan man a few pieces of dry laundry at his monument’s expense.

Trouble with weapons

2008-04-06T06:56:00.000-07:00

Clear your weapon here: Although this sand-filled clearing barrel can stop an errant bullet, your weapon should be free of ammunition before you put the muzzle in and pull the trigger.

A principle of proper gunmanship is that, even with an unloaded weapon, you must at all times maintain “muzzle awareness.” A basic tenet of muzzle awareness holds that should you never point the barrel of your weapon at another person. It would seem easy to avoid such a scenario, but at times it requires quite a bit of attention and concentration to keep a muzzle directed safely away from everyone else, as when you have a rifle slung across your back and you are trying to move through a crowded dining room. Getting in and out of vehicles with weapons can also present a challenge, and I’ve been poked a few times in the leg and ribs by the business end of a colleague’s rifle as he struggled to get into a Humvee or armored truck while wearing fifty pounds of body armor.

Those incidents didn’t bother me much, as I know the improprieties were a consequence of the burdensome physical load the person was carrying. But what does annoy me is the “flashing” to which I’m subjected daily. If you are devoid of muzzle awareness and allow the barrel of your weapon to point directly at another person, you flashed him. During weapons training in the US and Kuwait, some people were notorious for flashing the rest of the platoon with both loaded and unloaded weapons. At one firing range exercise, another officer turned from the targets with her weapon still raised to ask the instructor behind her a question. Two dozen people behind her immediately fell to the ground as she flashed her loaded weapon at a line of people waiting to walk onto the range. The instructor flinched as well. On the base in Kabul, many people carry a pistol sheathed in a shoulder holster that should hold the gun under your armpit with the barrel facing groundward. Think Jimmy Smits as Detective Bobbie Simone on NYPD Blue. Yet every day I see several people walking with holsters that, because of comfort or misfit, maintain the pistol barrels parallel to the ground, thereby flashing everyone behind them.

When on base, we keep the ammunition magazine out of a weapon and the weapon’s status is termed “green.” If we leave the base, however, we are supposed to lock a magazine of bullets into our weapon, and with ammunition inserted the status of the weapon changes to “amber.” A weapon is considered “red” when a magazine is locked and a round of ammunition is loaded into the firing chamber, hence the phrase “locked and loaded.”

Even in amber status with the safety mechanism applied, a pistol can be dangerous when you are riding on the rough pocked roads of Afghanistan. A bullet can be chambered inadvertently, the safety switch can be jostled to fire, and suddenly you’ve got a weapon asking for an unintended victim. Which is why I became very nervous very quickly last week when a medical officer riding shotgun (but thankfully without one) in my vehicle had an amber weapon in his shoulder holster pointing not toward the floor but between the front two seats and directly at the head of another officer sitting next to me. We quickly pointed out his breach of muzzle etiquette, but his lackadaisical response was “Oh, that’s just the way my holster holds the pistol.” He made no attempt to adjust the pistol’s position. I politely proposed that the two of us in the back seat aim our pistols directly at his skull so that he could enjoy the same level of comfort we currently were feeling on the trip. He begrudgingly unholstered his gun and held it in a safe position for the remainder of the trip.

From what I’ve seen so far amongst the staff officers with whom I serve, I’m much more likely to take a bullet from someone I know in an inadvertent weapon discharge than to be shot by an insurgent. Personnel from my command carry rifles and pistols for self-defense, and I think we need them when we travel into some areas of Afghanistan; but the primary danger for anyone traveling in Kabul and environs, and maybe the whole of Afghanistan, is an encounter with an improvised explosive devise on the roadside or a suicide bomber on foot or in a vehicle. A personal firearm will do little to nothing to prevent or mitigate that type of attack. We routinely discuss the possibility of taking small arms fire during vehicle convoys, and the plan is always to drive through the attack if it happens. I certainly don’t plan to exit an armored, moving vehicle to search for a sniper if a few unwelcome bullets come my way.

My fellow staff officers and I are not combat arms specialists and we are not nearly as familiar with our weapons, and perhaps we are much more uncomfortable handling them, than is an infantryman or even an enlisted sailor. When we return to our base from a mission, base regulations require us to clear our weapons of any ammunition. The process is fairly straighforward: you first release the magazine of ammunition from your weapon; then you pull the slide or charging handle back to expose the firing barrel and to visually ensure that no bullet sits in the firing chamber; and finally you take your weapon off safe, point the muzzle into a large red clearing barrel and pull the trigger. You should only hear a click when you pull the trigger, as you have already emptied the weapon of ammunition and visually cleared the weapon’s firing chamber. Several times in the past year, however, officers here heard more than a click as they put a slug into the sand packed-barrel designed to smother such errant bullets. That’s called a negligent discharge, and it earns you a visit with the commanding general on base.

Recently only officers have been guilty of negligent weapon discharges on this base, a fact that delights most of the enlisted personnel. Thankfully, the clearing barrels have absorbed only a few bullets. The officers who thought that assaulting the barrels was appropriate may have felt rushed to clear their weapons or they may have been temporarily distracted, but they breached weapon protocol nonetheless.

Some of these officers might also have suffered the illusion that the clearing barrels serve as final barriers to any harm that might come from their inattentiveness. A colleague commented to me “What’s the big deal if you fire a round into the barrel? That’s what it’s designed for.” But that’s dangerous thinking: The barrels are there to ensure that a weapon is empty of ammunition even if the handler fails to clear it properly. Personally, I don’t want to be near a clearing barrel when it is occupied by someone looking for a close-quarters firing exercise; and I’ve seen inattentive people clear a weapon with the thing pointed somewhere toward the barrel but certainly not safely inside of it. In fact, when I heard of the negligent discharge at this base, I was momentarily impressed to learn that the bullets at least made it into the barrels instead of finding nearby metal and wood and flesh.

Afghan Star and the Afghan Paula Abdul

2008-04-05T07:22:00.000-07:00

Photograph: I pose with Monisa, the Afghan Paula Abdul.

Hollywood studios might be the agencies best able to capture the hearts and minds of Afghans. Witness the recent success of the third season of Afghan Star, a television program modeled on American Idol. Afghanistan has a population of approximately thirty million people, most of whom live in impoverished rural areas with few luxuries; but an estimated ten million people watched the final episode of Afghan Star last month. I was impressed that one-third of the country’s population had access to a television. Small towns and villages across the country aired public broadcasts of the show that is the most popular television program in Afghanistan.

Saad Mohseni , founder of the television station that produces Afghan Star, thinks that his television show will bring about social change in the country. You might scoff at the idea that popular entertainment might foster anything but brain death, but consider Mohseni’s quotes: “… people voted, … they lined up in an orderly manner (outside the show) … the losers are gracious. No one is threatening violence. That’s a huge change.”

Afghanistan is a country without a history of democratic elections and where sectarian leaders have traditionally compensated for a political or military defeat by lobbing mortars at innocent civilians. I applaud any effort that models good sportsmanship. And any initiative that convinces a crowd of Afghans to organize themselve into an orderly formation should be carefully analyzed and studied for implementation in different social spheres. I’m thinking that Mohseni is correct, and perhaps the United States might want to modify our engagement strategy with the Afghans by providing every household a television set and wiring the country for digital cable access. We might also want to work a little harder to get urban areas like Kabul reliable electrical power to facilitate prime time viewing. And we shouldn’t forget that most Afghans still lack clean drinking water, proper schooling, medical care …

But back to Afghan Star. Like American Idol, Afghan Star employs a panel of judges to select the winner. The Paula Abdul equivalent is Monisa , a native Afghan woman who has lived for awhile in Germany studying music as an acedemic. She recently returned to Afghanistan and now is completing a clerkship in medicine at the National Military Hospital in Kabul, where I met her today. Like Beyonce or Madonna, she is popular enough to need only one name, and she’s the only woman I’ve seen in Afghanistan who does not cover her hair with a scarf in public. Thankfully, she has also avoided Abdulian displays of public disorientation and suspected intoxication. My Afghan interpreter identified her as the Afghan Star judge, after which I approached her and said “I saw you on tv and would like to take my picture with you.” Like every other Afghan I’ve met, Monisa was thrilled to pose for a photograph.

Baking na'an

2008-04-02T11:33:00.000-07:00

Na’an is an unleavened flat bread and a staple of the Afghan diet. The Kabul Military Training Center has its own bakery on the premises as the demand for na’an is so great, and I visited the facility this week. The bakery building itself is rather nondescript and surrounded by discarded shipping containers, scrap metal and disorganized collections of firewood. If a single-wide mobile home sat there, you would swear you had stumbled upon a cyclone-ravaged disaster area. One my colleagues thought we had walked to the dump.

I’m not sure why the metal collection outside the building, but the firewood was waiting to feed the wood-burning ovens in the bakery. Firewood is a valuable commodity in Kabul as few trees grow in the dry terrain surrounding the city, and this wood reportedly came from the southern regions of the country. Oddly, none of it was stacked near the doors to the bakery. In fact, none of it was stacked at all but strewn as far as thirty yards from the sole entrance to the building. Already I have learned that the Afghan idea of organization often differs significantly from mine, and since the heat emanating from the bakery indicated that wood was indeed making its way indoors somehow, I gave no more thought to the disorder outside and ventured into the building.

The bakery had three rooms, each with a stone oven that resembled a hive with a large hole in the front. Underneath each oven was a raging fire. As it is now spring in Kabul, the heat was not crippling; but I wondered how high the temperature of those rooms will rise during >100 degree summer days. In each room one man worked at the oven, taking the fresh disks of flat dough and pressing them onto the stone ceiling. I was happy to see that for protection from the stone's heat all of these gentlemen wore gloves -- the only concession to occupational safety that I could identify in the entire place. After the disks had baked a few minutes in the oven, the bakers picked them off the stone with a long iron thongs and tossed them into a collection bin.

The other workers in the room were busy mixing by hand fifty pound bags of flour with water, then rolling the dough into balls before pressing it into disks. These other men also spent considerable time and energy imploring me to take photographs of them. Almost every Afghan I’ve met has been thrilled to pose for a photograph. If we really want to stop the Taliban, my recommendation is that we arm front-line soldiers with digital cameras and color printers, because if the Afghan insurgents are like their fellow countrymen they will interrupt any activity to pose for a snapshot; and they will wait to resume previous activity if you promise that a copy of the photograph is coming soon.

As a visitor and because I was taking photographs, the workers showered superfluous hospitality on me by baking a special sugar bread. It was simply a regular na’an loaf with sugar sprinkled on top, but I felt lucky as it was the Afghan equivalent to being in Krispy Kreme when the hot light is on and you get a fresh original glazed directly from the oven. The sugar loaf was delicious, as the exterior of the na’an had a crispy sweetness and covered a thin inner layer of warm dough. The flour tastes like a hybrid of white and wheat. If Afghanistan has an event similar to the Indiana State Fair, the sugar na’an likely holds the same status as an Elephant Ear or Funnel Cake.

Earlier I referred to the workers as men, but most looked to be teenagers – a few very young teenagers. A translator told me the daily wage there was less than $1, but you got all the na’an you could eat. One of the rooms also offered free Bollywood movies on a portable television with a small screen but surprisingly powerful speakers as that section of the bakery sounded like an Indian discotheque. I spotted a worker wearing a Cleveland Indians t-shirt complete with a large depiction of the arguably racist Chief Wahoo, mascot of the team. Dr. John Kim, a colleague of mine and a native of the metropolis formerly known as The Mistake by the Lake, rushed to get his photograph taken with this Afghan who was completely befuddled by our interest in his clothing. Western garments, especially those discarded, outdated, unwanted and mistakenly produced, make their way to developing countries and to people who see them simply as valuable wardrobe additions, usually with little knowledge of any graphic that might adorn the clothing. In Eldoret, Kenya I once saw an elderly native man walking through town with a shirt that had “F - - k You!” written across it. John and I are on the lookout for t-shirts proclaiming “New England Patriots, 2008 Super Bowl Champions. “

Boot Camp Afghan Style

2008-03-31T07:54:00.000-07:00

Double-click images for larger photos Left – New recruits in an Afghan military formation. Center – Colonel Bahomodeen takes issue with the fat content of the recruits’ lunch. Right – I give a little ophthalmic instruction to the physicians.

A Day at the Afghan Army Recruit Processing Center

Today I went to the recruit processing center for the Afghan Army. The physicians there had requested an ophthalmologist visit the facility as they had some concerns about the vision screening done at the center, and I gladly went with several senior officers from the Army public health division who had other areas of the facility that they wanted to inspect.

The Afghan general practice physicians who work at the center were very professional and spoke excellent English. They had good equipment to work with, including an auto-refractor that scans the eye and quickly determines a prescription for glasses; and a phoropter for determining the prescription manually. (You know the drill: "Is it better at one or two? Three or four? ...") The physicians knew how to operate both pieces of equipment, more than what most non-ophthalmologists in the US can do. They even had questions about the use of positive or negative cylinder when determining a patient's refractive error. If you have no idea what that means, don't feel alone as typically only ophthalmologists and optometrists get trained on such issues. But the fact that these two general practitioners were facile with the concept impressed me tremendously.

They recounted for me that it was not unusual for them to prescribe glasses for a recruit only to have the patient complain that the spectacles did not give them crisp vision. The percentage of recruits that need glasses at all is low: They estimated that only five percent got prescriptions when they arrived for processing. They weren't sure what they are doing incorrectly. The likelihood is that they are not doing anything incorrectly, but instead that these recruits have other ocular conditions such as cataracts, tear film abnormalities, strabismus, corneal pathology or retinal disease that reduces their visual acuity. The clinic had no slit lamp for proper evaluation of the eye, so our plan is to procure that equipment for the clinic then conduct a short course in eye disease and examination skills given by Ronald Willy, M.D.

I also postulated that some recruits might be rethinking the whole join-the-new-Afghan-Army-and-fight-the-Taliban plan that sounded so appealing when they were back in their villages dreaming of what they would do with the $40 monthly salary plus room and board offered recruits. Upon hearing this theory, my colleagues laughed and agreed that they thought “soldier’s remorse” was a significant factor. I explained that it was not uncommon for a US military recruit to discover he was suddenly blind in one eye after two weeks of boot camp.

Recruits are crafty creatures, no matter what their ethnicity and culture; and when it comes to factitious illness they often are difficult to treat as you cannot simply play Mr. Goodwrench and hook these guys up to a diagnostic device that determines “legitimate knee pain” or “retinal degeneration leading to poor vision.” Physicians at the Afghan Army National Medical Center recently recounted for me how newly trained soldiers took advantage of the decrepit conditions at a local barracks and blamed their physical environment for inducing illnesses that left them unable to perform their duties. Not surprisingly, every soldier who suddenly took sick was slated for transport to an isolated duty station somewhere in the Afghan hinterlands. The soldiers awaiting duty in Kabul itself reportedly were in fine fettle.

Recruits arrive at the processing center regularly. Many come from the provinces, have lived in rural areas their entire lives, and are in the "big city" of Kabul for the first time. The clothing they are wearing when they arrive is usually their sole possession. We visited a barracks building and found beds nicely made but lockers completely empty as this group of recruits had arrived the previous day and had not yet been issued any Army clothing or their "hygiene packs" with soap, shampoo and other toiletries. The barracks had nicely tiled bathrooms and shower facilities, which are foreign to many of the recruits who must be taught how to use a modern faucet.

Like most Afghans I have encountered so far, these recruits LOVED posing for photographs. Well, they didn't really pose as they were sitting in a quasi-military formation and had officers watching them; but they clearly enjoyed our attention and my statement that if they were joining the American Army, they would be getting their heads shaved bald like mine (at which point I removed my hat). I got several photographs of the platoon and found myself fascinated by their traditional Afghan dress and differing facial features. Most of the men -- and they were all men -- were in their 20s and surely had seen considerable suffering and violence their entire lives as the past few decades have been devastating for Afghanistan.

Afghan society is very hierarchical, and when the colonels from my group got to these recruits they immediately began to remove their hats to check their hair (for lice and other disease, I suppose) and pull back their outer garments to check the cleanliness of their underwear. Understand that the colonels all are educated, from influential families, and wealthy by Afghan standards, so the recruits and other officers raised no objections to this impromptu inspection. In fact, the recruits seemed to enjoy the attention and clearly understood that the colonels were yelling about the need for clean new clothing for the entire group (which, along with three square meals daily, was probably a prime motivating factor for these guys to enlist.)

The colonels also raised hell in the kitchen when they saw floating in two large tubs of water the wedges of meat and fat destined to be lunch for the recruits. Colonel Bahomodeen, a veterinarian and a kindly older gentleman who was dressed in a suit and tie, reached into the vat and pulled out pieces of frank fat and began yelling that you cannot feed such product to soldiers and expect them to be happy and healthy. The kitchen staff seemed to get the message, as about ten of them started fighting each other to get to their hands into the tubs to remove the fat. Colonel Bahomodeen did concede that some fat should be left in the mix for “flavoring.”

As we left the recruits, I noticed many were staring at my female colleague, Dr. Illy Dominitz. I doubt they had ever seen a woman in public without her head covered. Illy was standing before them with head bare, in a military uniform, carrying a pistol. I’m sure some of them were thinking “The stories we heard about the strange things in Kabul really are true.”

My kind of people

2008-03-29T07:09:00.000-07:00

Photograph - Lt. Col. Mohammad is the gentleman on the far left. His image is blurry as, even with my shutter speed at the fastest setting, I couldn't capture a clear photograph of him due to the speed and vigor with which he attacked his lunch.

The Afghans Come for Lunch

Shortly after I arrived in Afghanistan I heard from reliable sources that food is of significant importance to most people here. Not surprising, I thought, as both the Afghan economy and farmland are poor. But I soon learned that the Afghans are like the Chinese in that they really don't place much value on clothing or housing or any other suspected personal artifice, but they insist on eating good food -- and a lot of it -- no matter what their financial state. History and genealogy would confirm this common bond with the Chinese, as a significant percentage of Afghans carry the genes of Genghis Khan; and one minority group, the Hazara, have facial features you'd expect on a world table tennis champion, not a Shi'ite Muslim from Kabul.

Today I lunched with six top officials from the Afghan Army's public health office, and I was astounded by the sheer quantity of food they consumed. I heard before they arrived that they relished any opportunity to eat at the dining facility on our base, and it was clear they understood the logistics of dining here and the variety of food available to them because they worked the buffets as if they had already run reconnaissance on the place. They seemed to know exactly how many pounds of food the rather flimsy paper trays could hold as they loaded on lunches that included grilled chicken breasts, fried chicken tenders, roast beef, chicken wings, deli meat, enchiladas, egg rolls, taco beef, turkey wings, macaroni, french fries, salad and several selections of fruit and potato chips.

In the past I have worked extensively with Cambodians and Indonesians who, to a person, were hesitant to eat anything unfamiliar and who usually subsisted outside their countries on rice and simple grilled chicken. The Afghans I dined with today showed no hesitation in consuming entrees unknown to them. I don't think enchiladas are an Afghan staple, but when my guests learned that beef resided inside the corn tortilla, they nearly lifted the entire tray from the steam table. I fashion myself a pretty big eater, but I felt a post-prandial fatigue coming on just watching these guys dish themselves 6-7 entrees apiece.

For the first time, I felt a solidarity with the Afghans. They are my kind of people. The lunch also gave me renewed hope for the development of Afghanistan because if these men are able to marshal to their advantage the vast mineral wealth found in this country as competently as they mined and consumed the myriad offerings at the dining hall, Afghanistan will be a first-world country before I fulfill my Naval commitment.

Never believe that Afghans lack creativity or ingenuity. I saw at lunch roast beef in a peanut butter sauce, french fries on a bun, chocolate chip cookie-crusted chicken, broccoli-infused enchilada casserole and cranberry Coca Cola. Two men ate sour cream straight up, with no chaser. I lived in Japan for year and thought the Japanese took extensive liberties when preparing American cuisine, but the Afghans brought together disparate elements that would have sent any reasonable Japanese diner back to the sushi bar. And the Afghans consumed enough to shame eating champion Kobayashi.

I was charged with procuring and delivering desserts at the end of the meal, and I wanted to test the resolve of my guests so I brought each one of them two desserts, a bowl of ice cream and a large piece cake, in addition to a selection of cookies for the group. I was lucky to snare the last peanut butter cookie as every treat seemed to vaporize before I could reseat myself.

A coworker asked if perhaps these men ate so voraciously because they seldom enjoyed such a large and varied selection of food. I doubt that is the case. Anyone used to eating light would NEVER have been able to wolf down one-quarter of the lunch these men devoured, and most well-nourished people would be risking nitrogen poisoning from an overdose of protein had they been going tamale-for-tamale with them. I say again, the Afghans are my kind of people.

I wish our encounter had ended in the dining hall, but these dignitaries had a secondary agenda that included the promotion of public health in Afghanistan, so we retired to a meeting room to endure a presentation detailing ... the rancid conditions of most slaughterhouses in Afghanistan. My stomach is pretty strong, but I might go vegetarian for awhile after seeing photographs of a butchering facility located very near our base, and I don't recommend anyone else sit for such a presentation just after a meal. Upton Sinclair would have been too ill to write The Jungle had he visited this place. A cat served as rodent control, and that was the most progressive element of the facility. I'm not going to post any of the photos as too many people would be disturbed by them and a few images might risk categorization as pornography, but the lowlights include blood stains five feet up the walls, men with slaughtering knives in their mouths as they struggle with animals, and a line of dead goats bleeding out into an open trough.

I'm a physician and I've seen quite a bit of human gore, but those photographs really made me queasy; and I realized half-way through the presentation that I was so unnerved because what I was viewing could be my food. My Afghan colleagues, though concerned with the conditions they reviewed, did not seem viscerally disturbed: As they commented on strategies to clean up the slaughterhouses, they munched on M&Ms and Skittles and small chocolate Easter eggs. As I've said, these Afghans are my kind of people.

Rebuilding means something used to be there

2008-03-26T06:48:00.000-07:00

I've been in Afghanistan for two weeks and only now am I beginning to get an idea of what my job will be. Unlike most people who arrived with me, I was not a direct replacement for a departing officer. That means I had no turnover brief or orientation to my job responsibilities or clear explanation of exactly what I'm supposed to complete or supervise or promote for the next twelve months. I'm new and my position is new, and that can be advantageous, or disastrous. As an example, as a staff officer, I am considered available to fill space on any "advisory board" or "working group" on base that needs representation from medical personnel. My military experience such groups has been that they advise very little and work even less. It's hard to maintain consciousness when your day is enveloped by their meetings, and the incessant dozing they induce plays havoc with my ability to sleep through the night. So I'm trying to create a few specific duties and projects for myself that might keep me occupied and focused during the day. I might even be able to assist the Afghan Army in the development of its medical system.

The US Navy has teams of physicians, nurses, hospital administrators and other health professionals "embedded" at different Afghan Army and Police hospitals and clinics throughout the country. These teams typically live on the grounds of these facilities, and they can probably count on one hand how many times they leave the premises during their 6-12 month deployment. In Kabul, at a base small by American standards but pretty large relative to the hospital grounds in Mazir-e-Sharif or Herat, sit me and other administrative and leadership staff who work to direct and support the embedded teams. "Direct" might mean that we implement through the embedded teams a trauma care plan devised by the Surgeon General of the Afghan Army. "Support" might mean that we procure a means of refrigeration for vaccine doses spoiling in the heat of Kandahar.

My first task has been to formulate a monthly reporting scheme for the embedded teams in order to better track their progress in mentoring the Afghans to provide better care for soldiers and their families. So far, reports from the regional hospitals have varied from "emergency room here is really coming into its own and better caring for patients" to "staff still loathe to wash hands before entering the operating room" and "surgeons no longer using the same set of instruments on two different cases simultaneously." Much of the mentoring here is very basic. The facilities are called hospitals, but an American would hardly recognize the organization and services provided within. A significant percentage of any hospital staff is likely illiterate, and that makes record-keeping a bit difficult. Many of the nurses have had no formal education. A physician may or may not have attended medical school classes or passed any formal licensing or certification exam.

They're not dishonest. For the past several decades, Afghanistan has not been able to offer most citizens the opportunity for a good primary and secondary school education, let alone quality medical training. No uniform, objective training standards seem to exist for these positions. An Afghan ophthalmologist told me that after his medical school training, he passed both the internal medicine and surgical exams, and he decided to practice ophthalmology. I'll admit that a language barrier was present, but I could not elicit from him any recount of focused ophthalmic training he received. It appears that local surgeons simply select the specialty that interests them most. A colleague told me of meeting the Chief of Surgery at a provincial hospital who pleaded for a different professional post as he trained in internal medicine, and had not even attended a surgical case as a medical student.

US military medical professionals are working for improvements in Afghan military healthcare as our efforts are part of a larger strategy to improve Afghanistan's internal security by reinforcing and expanding the national army and police force. American medical personnel are engaging the Afghan healthcare system at the clinic and hospital level. Progress is often elusive and usually precarious. If an Afghan hospital represents the pinnacle of healthcare here, the illustrious apex of a pyramid, then any embellishments to its facade stand in danger of collapsing groundward as the elements of a solid structural base necessary for a society to sustain advanced care -- a high literacy rate, adequate economic resources, sustained electricity -- are usually lacking. Afghanistan is a development project at every level. Few geographic and societal sectors in Afghanistan are being "rebuilt" as they have never existed. Progress should be measured in small increments as the task is monumental.

There are professional assets here: Afghanistan has dedicated, intelligent and sometimes well-trained medical professionals, although not nearly as many as needed. The US is attempting to mentor some of these people in hope that a partnership will result in better care for all Afghans, a necessary element for the country if Afghanistan is to be a stable country that doesn't pose a threat to America. That's the US military's goal for Afghanistan, our current "end-point." With respect to Afghan medical care, the project will be decades long. The medical education tract begins with a basic education and then continues as prospective healthcare professionals progress through a training sequence that takes many years. The US has been in Afghanistan intermittently for only seven.

Strategy 101: Why not join a legitimate protest?

2008-03-23T01:06:00.000-07:00

You would be understating the situation if you claimed that Afghanistan operates idiosyncratically. As an example, the country's time zone is not Greenwhich Mean Time plus four hours, or Greenwhich plus five, but Greenwhich plus four and one-half hours. No one here has been able to provide me a compelling argument for the advantage of a country keeping its hours unsynchronized with those of its neighbors and most the rest of the world. The official Afghan calendar differs not only from the Gregorian calendar of the West, but from the standard calendar of Islam. Most Muslims worldwide celebrated the beginning of the 1429th year of Islam on January 10, 2008, the new year according to the lunar calendar; but Afghans adhere to a Persian solar calendar and just last week welcomed in year 1387.

The actual date of the Prophet Mohammed's birthday is not known, so Muslims typically celebrate his birthday in the third month of the new year. We infidels in Kabul were confused by the national holiday last week that accompanied the arrival of the solar new year, as we were three months into the Islamic lunar calendar and we didn't know if it was simply a celebration of the new year, or the new year plus the Prophet's birthday; and if they both deserved celebration, which one took priority; or if Afghans celebrate the Prophet's birthday in the third month of their solar calendar year, should we prepare for birthday festivities three months from now.

I'm not surprised that progress comes slowly here, as many people working in the country cannot answer with any certainty the questions "What year is it?" and "What time do you have?"

I was hoping that holidays in Kabul bring the sight of kites in the air, kite runners in the streets, and lamb kabobs on the grill. I saw and smelled none of that. Security experts here warned that some angry Afghans might be using the holiday to promulgate mayhem in the streets of Kabul by hunting down Westerners, so I spent the time restricted to the base. The holiday itself was not responsible for promoting native anger, but instead American officials feared a backlash against anyone European in appearance due to the February republication in several Danish newspapers of the infamous 2005 cartoon depicting Mohammed with a turban fashioned as a bomb; and the supposed upcoming release by a Dutch politician and filmmaker of a documentary that equates Mohammed with Hitler and the Koran with Mein Kampf.

The holiday incorporated a Friday, the Islamic weekly holy day when Muslims attend mosque. The rumors were that a number Afghans, angry with the Prophet's treatment in Europe and free from labor the afternoon subsequent to services, would break from the mosques primed by their imams' fire-and-brimstone damnation of all things European and proceed to stalk the streets of Kabul with AK 47s and hand grenades as they made their way to the Dutch Embassy to let Holland, Denmark and the rest of the world know, with the sound of gunfire and the smell of cordite, that they took great umbrage to this depiction of Islam and its founder.

Understand that guns and other weapons of battle are not uncommon finds in Afghanistan, a country that some argue remains the domain of sectoral war lords. If you swept a few square blocks of Kabul at any time of any day you would likely would a find a disturbing percentage of the population with weapons that the NRA would have trouble justifying as noble possessions. To claim that an Afghan street demonstration might feature guns is akin to claiming that New York City's Puerto Rican Day Parade might be short of Port-a-Johns.

But the typical American reaction to such a prediction is a flurry of expletives followed by preparations to hunker down in a secure building with soft drinks, potato chips and a TV to wait out the violence.

This theory and practice of "bunkering" to me seems counter-productive to the overall US goal which is to win the "hearts and minds" of all people Afghan and Islamic. I think this past holiday in Kabul, we Americans missed a chance at solidarity with and understanding of Afghans and Muslims. Instead of sheltering ourselves in our fortified compounds to wait out the anger and feared violence, we should have joined the angered Muslims in their protest. We should have met them, as they surged from the mosques, with sandwich boards in Dari reading "Follow me to the Dutch Embassy" and "Burn Danish newspapers, not Kabul." We should have changed the placards on the rear of our Humvees from "Stay 100 meters back or you will be shot" to "Honk if you read the Koran today." We should have patrolled the streets with loudspeakers suggesting that we protest vociferously for awhile before retiring together for a pleasant evening of tea and kabobs.

The Dutch film deserves protest, as it reportedly lambasts the founder and the book of a religion that has produced great learning and liberal thoughts. Islam was a repository of ancient knowledge and writing while the priests and rulers in the West were burning books along with anyone thought heretical during the Middle Ages. Islam helped the West revive itself after a very dark period. Not exactly the stuff of Mein Kampf. Take a look at the photo above of the Dutchman, Geert Wilders, responsible for the film. The man dyes his hair platinum blonde to to call attention to himself. If his art and analysis are as plastic, superficial and comical as his appearance, then he should be shunned.

Protests and demonstrations in the US are seen as expressions of freedom; they are considered spectacles of a thriving democracy. But the prospect of a protest against us, especially when conducted in a foreign land, seems to trigger only fear and trepidation and ruminations on impending danger. Part of my job and the responsibility of countless other military personnel here is to mentor the Afghans as they build their country and transform their society. We missed a good opportunity last week to model for them the preferred protocol in liberal democracies for public protest and the expression of collective anger and grievance.

There were protests in Kabul over the holiday, and the news agencies reported that the participants, whose numbers ranged from a few hundred to several thousand depending on the source, were calling for the departure of the Danes and Dutch from Afghanistan. They also burned various flags and chanted "Death to America." I'm not sure how we got linked with the Europeans on this issue, but I do know that it might have been different had we joined with the protestors, not hid from them.

The Taliban cannot stop March Madness! And something called Buzkashi

2008-03-21T07:37:00.000-07:00

Modern warfare has become very user friendly as, at most US military bases, the internet and cable television are readily available. Therefore a ceasefire need not be called for March Madness, the NCAA basketball tournament. (Yes, Helen Cheng, this is the BASKETBALL tournament. The Kansas game we watched in January was football.) I am so happy with the tournament coverage here that I even look forward to Dick Vitale and his shameless ACC apologetics.

My beloved Marquette Hilltoppers/Golden Avalanche/Warriors/Golden Eagles (our mascot changes every 20 years) punked Kentucky for a first-round victory, and next we face Leland Standford, Junior College. Let's hope the damn tree that somehow serves as Stanford's mascot doesn't get too close to Marquette's players and handicap them by inducing corneal abrasions with its branches. Let's hope as well that Stanford's band is NOT present at the game as it is likely to charge the floor before the game is over.

The game telecasts in Afghanistan start late in the evening and proceed overnight, so the tournament has not been good for productivity in the office. With pre-game prognostications and post-game analyses, then the games themselves, my colleagues and I are spending 10-12 hours daily following the tournament and our personal brackets. That doesn't mean we aren't in the office. Very few people have televisions in their rooms on this base, but the offices have sets and access to AFN, the Armed Forces Network, which has devoted two channels, AFN Sports and AFN Extra, to the tournament. So although we are not exactly working, we can claim to be in the office all night long. The dining facility always serves a midnight meal as people work around the clock here, and the "mid rats" (midnight rations) are welcome as I adjust to a nocturnal life for the next few weeks.

Most NCAA tournament devotees know that much of the event's excitement comes from entering the office pool and testing your bracket of winners against that of your coworkers. Usually there is an entrance fee. As gambling is haram, or forbidden by the Koran; and since gambling is illegal on US military bases, we cannot and would never consider having an entrance fee for such a pool here in Kabul. Therefore, we play for "jellybeans." It's twenty "jellybeans" to enter the pool, and you take home more "jellybeans" if you win. "Jellybeans" also come in handy here when playing poker and rolling dice.

I don't think the Afghans really appreciate the enormity of March Madness. So I have to say that a University of Georgia hoopster was overstating things just a bit when he stated that the Bulldogs "shocked the world" the night they unexpectedly won an NCAA berth by taking the SEC post-season title. Basketball from any league is not a passion among the Kabul locals. Sami, one of our office custodians, has heard of Michael Jordan but could not tell me what sport His Airness played, although he did mention "the Bulls of the Chicago."

Afghans reportedly are more fond of flying kites (although I have yet to see one in the skies over Kabul) and a traditional sport called buzkashi. I would classify buzkashi as a variation of polo, as men play on horseback; but I doubt Prince Charles could be persuaded to suit up for a sport where the object is to carry a dead, disemboweled, decapitated calf the length of a field while other riders use any means possible to thwart you and take possession of the carcass. (See photo above.) Cricket must have influenced the evolution of buzkashi, as a match can last several days. To toughen the skin of the calf for such an extended contest, the carcass is soaked in cold water for 24 hours before the competition. A goat can be used if a calf is unavailable or too expensive, although aficionados claim the goat carcass tends to disintegrate before the end of the match.

Afghan Women Part I: Encounter with the burka

2008-03-19T06:56:00.000-07:00

Although not the most beautiful of Afghanistan's cities, Kabul is by far the most cosmopolitan: the social and cultural Afghan equivalent of New York, Los Angeles and Washington, D.C. melded into one metropolis. And although Kabul boasts very little in the way of glamour, investment capital and strong governance, you can find here educated female professionals who wear Western garb (although always with a head scarf) and compete successfully with the menfolk. Yet the streets of Kabul also provide reminders that most Afghans live by a familial and social code much different from what is acceptable to an urbane Westerner. Perhaps this cultural divide is best exemplified by the burka worn by many women here.

My most unnerving moment so far in Afghanistan was when I passed within a foot of a woman wearing a burka who was walking the direction opposite of mine. I know that I am not supposed to stare at these women, and I didn't; but I felt myself transfixed as I had difficulty believing that what I saw coming toward me was an actual person. That's exactly the response the burka is supposed to elicit in a man, I suppose. I would not be acting properly if I acknowledged her in any way, as she is someone else's property and not considered an individual at all. The burka was effective in negating her as a person as I passed.

Other women comport themselves in public completely covered except for their upper faces, but I don't find that garb at all disarming as you can see the woman's eyes and they acknowledge, even if they don't look at you, that a human being exists under the robes. Not so with the burka. You cannot see through the mesh covering the woman's face. With their feet hidden and the sheets of the burka loose and flowing, these women are blue apparitions coming toward you. Sometimes you can see bony hands and fingers jutting from under the burka, but that only adds a grotesque, skeletal component to an otherwise sad and somewhat frightening scene.

This week I attended a lecture at the Afghanistan Ministry of Public Health. Outside the ministry building sits Massoud Circle, a major intersection in Kabul. I stared through a second-story window as I waited for the lecture to begin, watching Afghans as they walked, biked and drove around the circle. Several women I saw wore burkas, but two women held my attention more than the others. They were both in burkas, accompanied by one man, and sitting together several feet off the circle. The three looked as if they were awaiting transportation; and even though already fully covered, the two women faced away from the busy circle toward a stone wall. (See photo above.) They spoke to one another, but their clothing and position made it impossible for them to interact at all with the people around them. They took every measure available to hide their existence from the other people scurrying about near them.

The physician giving the lecture was a female Afghan physician who worked with the aid organization CARE to improve maternal-fetal health in Kabul. She explained how community educators, themselves literate local Afghan widows, tried to reach and educate expectant mothers. Many females in Afghanistan marry older men soon after the women (girls, really) reach ten years of age, even though the legal age for matrimony is sixteen. In order to educate a pregnant woman on nutrition, pre- and post-natal care, and the local medical services available, the community workers first gain the sanction of the local mullah, the Islamic leader, and then the woman's mother-in-law. (Often, an entire community of older women will meet as a shoura, an estrogen-soaked community council, to decide if they will accept the educators into their homes to speak with the younger pregnant women.) Usually, if his mother decides that an educator should speak to his pregnant wife, the husband will consent to an intervention in his home. But the husband alone determines if his wife will leave the house to visit a hospital or physician.

The social pressure for conformity and the engrained traditions found here can even overpower parents who want their daughters to educate and liberate themselves. I know a physician who helped sponsor a very bright young provincial woman so she could study law in Kabul. She was a stellar student. Her parents, who were quite proud of her learning and accomplishments, shocked everyone when they announced recently that they would be marrying the woman, who is twenty, to a man more than twice her age. They explained that they truly did not want to give their daughter away and force her to abandon her studies, but the pressure from their extended families was so great that they had no choice but to agree to the betrothel. The marriage will ensure that the aspiring lawyer returns to her village to spend the rest of her life as a virtual recluse.

In the beginning, there is disbelief

2008-03-17T08:43:00.000-07:00

A healthy percentage of people coming from developed countries to work in Afghanistan quickly find themselves in disbelief at the living standards facing the typical Afghan, even in an urban area such as Kabul. A report from the Rand Corporation entitled "Documenting Health" states that what data experts can gather on the country "clearly place Afghanistan at or near the bottom of every socioeconomic indicator used to measure human and economic progress." The social stagnation permeates every sector of both private and public life: most people suffer horrible sanitation and lack clean drinking water; women, especially the young females, are usually looked upon as chattel; the government often seems lacking, incapable or corrupt; good schooling is a luxury; most people could not even tell you what decent healthcare should provide; the country's infrastructure remains crumbled and crumbling due to war and neglect.

The country needs a continued infusion of donor intellect, money, and expertise to partner with the Afghan people and resources that are available and capable of transforming their society on virtually every front. The changes have to be accepted and ultimately directed by Afghans. But this partnering is difficult. Afghans have a culture and history quite distinct from most of the foreign nationals here to assist them, and Afghan priorities and decisions are sometimes befuddling. Progress comes very, very slowly here, even when Afghans and foreign development workers are working well together.

After the initial feelings of disbelief fade, frustration often sets in. Many of my coworkers have been here for six months or more (a relatively short time when you talk about nation-building projects), and they can spew endless tales of education and development projects sidetracked by forces beyond their control. Two senior corpsmen in my office are charged with implementing a combat medic course for the Afghan Army. One lesson focused on the placement of a tourniquet to prevent exsanguination if a limb is amputated. They demonstrated the tourniquet's facility in the classroom by placing it on a leg. In a subsequent practical exercise, the hypothetical victim suffered an amputated arm; but instead of addressing the severed limb, the Afghan soldiers placed the tourniquet on the victim's leg, as they had learned in class. Clearly, these soldiers had no working knowledge of basic physiology. Many of them were illiterate. How could they possibly know about the flow of blood through the body's vascular channels if no one had ever taught them? Western medical experts really didn't understand the basics of the circulatory system until the late 1800s. The Afghans' failure to place the tourniquet properly illustrates the cruel result of youth denied a fundamental education. And the frustrated corpsmen are struggling to overcome this educational deficit as they try to teach basic first aid.

I spent my pre-deployment training with an engineer who went this week to inspect a new building constructed for the Ministry of Interior. He was dumbfounded by some of what he saw. A few of the toilets were clogged or broken as Afghans, after defecating in them, used rocks to clean themselves and then flushed the stones along with their waste. They weren't vandalizing: many of them probably had never seen toilet paper before (or the paper dispener next to the commode was empty) and they routinely used rocks for such ablution. The new, industrial-sized kitchen in the facility was still spotless, which led my engineer friend to inquire if any cooking was being done there. "Oh, no. We cook out here," some Afghans told him as they led him through a back door to a yard where pots hung over improvised wood fire pits. I wonder if anyone had bothered to show these Afghans how to work a modern stove.

Hearing these stories, it is easy to conclude that Afghans are stupid and uninterested in changing. But the knowledge and technological savvy that Westerners possess are the result of learning -- we've been instructed on how to function in the modern world since we were toddlers. Our sophistication is not innate. We were taught to use a modern commode (although many of us rebelled against that instruction). Safe driving, operating kitchen appliances, the fundamentals of democracy such as voting and responsible political representation, the value of good hygiene -- all of these things, and many more, we learned because we grew up privileged. And we not only learned the lessons, but we learned that by applying the lessons in our everyday lives, we were much more physically comfortable and oftentimes emotionally better pff. The Afghans will learn these lessons, just as we did, but it will take time. You cannot expect to compress several generations of education and experience into a decade of development work.

Today I imagined myself in 1984, at age 18, sitting down to a computer with a Microsoft Windows operating system and internet connectivity equivalent to today's standards. I would have looked pretty stupid trying to operate the thing.

Afghan food, Afghan pride

2008-03-15T02:17:00.000-07:00

An Afghan general recently told my boss that an Afghan values three things above all else: food, sleep and gossip. (From my limited reading on Afghan culture, I thought that Islam, personal pride and revenge also were highly prized, but I'm from Indiana so I won't countermand the general.) I was glad to hear that food is a priority, as an abundance of good vittles ranks near the top of my own pyramid of needs. If I were free to roam off our secure base to explore the local cuisine, I might be able to comment more on the Afghan fare; but currently I'm pretty much restricted to Kellog, Brown and Root's American food in the dining hall as I checked with the security folks here and they quickly denied my request to organize a convoy for a tour of Kabul's kabob shops. But the value of food to the typical Afghan does help explain my first encounter with Tajib, the custodian at my office.

As I have no opportunity for formal language training here, I have taken to asking the guards and housekeepers, who are available pretty much 24/7, to teach me a few phrases in Dari. To a man, they have become quite excited when I, an American, express interest in something other than ESPN and the number of days remaining on my tour. In fact, most of them begin spouting phrases that I "must know, sir" so quickly that I don't have time to write them down. Usually there is an order to the vocabulary they toss me, but when I asked Tajib for the Dari equivalent of "How are you?" he quickly replied "chatur hastee, but sir you must also know of the health of man and for food. Sir, you must know carrot, zardak, and milk, shir. Milk!"

I didn't want to tell Tajib that I am over forty years old and what I need to be able to communicate is "Please direct me to the high fiber cereal," as I did not want to hurt his feelings or insult his personal pride; and I know he now considers me an ally as now every time he passes by me in the office, which is about 50-75 times daily, he utters with a smile "Mr. Ron!"

And even though the general didn't list pride among his top three Afghan values, I know it is important to men here; and I fear I may have inadvertently challenged the pride of my groundskeeper, Khirlal. I happened upon him my first full morning in Kabul when I was roaming outside and looking for the person designated as laundry man for my building. That position is quite an entitlement, from my perspective, as the going rate for washing and ironing a standard American military uniform is $3; and by my calculations a man would only have to wash and iron a dozen or so uniforms each week to earn an income exponentially greater than that of most other Afghans. However, the idea of washing and ironing must not strike Khirlal as work suitable for himself, as when I asked if he was my laundry person he gave me a glare that would have been appropriate had it been 1980 and I an invading Soviet infidel. But he did direct me to Suninal, who gladly took my uniform (that held about three pounds of Kuwaiti sand) and my money. As I departed I asked Khirlal, whose English is decent, to teach me the Dari equivalent of "thank you" and "good day" which he did with a smile but at such a pace that I didn't comprehend that Khirlal was not part of a phrase but his actual name (as to that point I had not learned what he calls himself).

I didn't have a problem that morning as I thanked Khirlal for his instruction and made my way to the office, but I was taken aback the next day when he approached me as I left my building and asked me directly, "Do you remember my name?" A quick smile will get you out of a jam most places on this planet, but apparently not in Kabul, as when I continued to smile and said nothing Khirlal gave me another glare, and this one would have been appropriate had it been 1980 and I an invading Soviet infidel who had recently torched his village.

Then -- and it stunned me for a moment until I clearly recalled that I had introduced myself the previous day -- I caught him looking at my nametape! I was in uniform, so my surname was embroidered above my right chest pocket and he had to read it before he said solemnly, "Willy, my name is Khirlal."

Well, I have pride as well, so I continued to smile and said "You cheated!" as I pointed to my name and then left him with "Salaam, Khirlal!" He looked at the end a bit nonplussed by my brazen retort. I like to think that now we both have a better understanding of each other.

I guess he really didn't like me

2008-03-13T05:46:00.000-07:00

Every day I walk a thirty-meter stretch of Kabul street heading to and from the military compound. By regulation I travel wearing body armor and helmet with my pistol loaded. My first day in Kabul I traversed this path a few times as I had several boxes and a few duffel bags to transport to my temporary living quarters. During one afternoon trip a slight Afghan man approached holding me while holding the hand of another male, a common sight here. What was uncommon, hopefully, was the movement of his free hand as he pointed to me and said firmly as he passed, "Sir, I hate you!"

Now I have walked the streets in many countries and on a few continents and I have heard many non-native speakers attempt a statement or two in English that failed to express the true feelings of the aspiring interlocutor. In fact, the evening after this incident I dined with an international group that included a French NATO colonel who approached us at dusk and bellowed "Good morning to you!" So I stand ready for liberal interpretation of the English of foreign nationals; but I think this particular Afghan expressed his feelings for me quite precisely.

I immediately thought of several reasons why he might experience acute displeasure upon sight of me. I was a foreign Naval officer walking along Afghan municipal streets in full battle uniform carrying a loaded weapon, and I was coming from a secure compound where international military forces enjoy an existence that is positively royal relative to the lives of most Afghans. While I conduct my business confident that appropriate financial remuneration awaits me at the month's end, most Afghans struggle to earn a few dollars each day. His government spends $1 per year on his health care, while mine provides me universal coverage.

He might have also thought, quite correctly, that if freed from my current military and environmental constrictions, I would be more than happy to drink and gamble and woo women as long as my stamina and wallet hold. These wanton pursuits are likely haram, or forbidden, by his religion. To me, they are the critical elements of a rejuvenating vacation.

If I spoke a bit of his language, at least as much as he knows of mine, I could have stopped him to ask more about his abject dismissal of me. But I was perspiring from the load I was carrying while sheathed in armor plates and I was tired from an overnight flight from Kuwait, so I didn't break stride when he addressed me; but I did mutter in Dari, the Afghan national tongue, the only phrase I know: tashak kur, or thank you.

Kuwait Part II: Faster Pussycat -- Jessica, Jessica!

2008-03-12T06:17:00.000-07:00

In this second and final installment covering my time in Kuwait, I was prepared to expound on many interesting and curious things both military and Kuwaiti. I was prepared to tell you about one training range, essentially a shooting facility and driving course carved out of sand dunes, where the temperature last year beat anything ever measured in Death Valley, CA, making it the hottest place on earth. (Thankfully I spent time there during the relatively cool Kuwaiti "spring.") I was prepared to tell you about the USO installation here where you are required to remove your boots to enter, leaving the Navy folk to dread the arrival of any new Marine battalion as that ensured the facility would produce the funk of 1000 soiled sweat socks.

I wanted to comment on the Bollywood Laundry run by third-country nationals blasting Indian pop; and the two-day sandstorm that delayed our training and had my colleagues agonizing over the consequent delay in shipping them to the war zone called Baghdad. I wanted to write about the innumerable, odd concrete structures that I discovered, on my own, to be mortar shelters; and the thousands and thousands of Jersey barriers that barricade and direct and restrict and cordon the movement of Humvees and trucks and people.

But I'm in a foul mood and not eager to address any of those topics as I had to depart for Afghanistan and missed my chance to attend the most exciting event to hit Kuwait since Sadam's invasion: the Jessica Simpson and Pussycat Dolls concert, sponsored by My Space. Jessica and the girls took the stage in "Kuwait Rock City" March 10, one day after I left the country. I've been unable to find much news on the event (perhaps Google Afghanistan blocks searches for such debauchery) as the popular press seems to have given it little attention and, ironically, the military restricts access to the MySpace website.

I did read that Jessica actually planned to sleep in a military tent, eat military meals, and spend only as much time as absolutely necessary with her traveling hairstylist. The Pussycat Dolls themselves, in a pre-concert interview, warned "the desert's about to get a lot hotter." Damn my luck!

The MySpace Kuwait Rock City event also featured comedian Carlos Mencia and a hip-hop singer and a couple of rock bands, but you didn't sense much excitement on base for these side acts. Everyone was anticipating the arrival of Jessica and the Dolls in-country

On base in Kuwait: Part I

2008-03-05T05:19:00.000-08:00

To ensure the operational security of US forces, I cannot reveal exactly where I am in Kuwait. But any US military member in Kuwait finds him or herself essentially in the same place: the desert. Regardless of what actual base you occupy. The sand that blows around and violates the exterior of all animate and inanimate objects is not the fine sugar found on Florida beaches, but a heavier composite that feels like fine dirt and is light brown in color. And everything that it touches -- concrete, metal, skin -- takes on a brown hue after repeated exposure.

The sand also tastes like dirt, and when the winds whip, as they have been doing the past two days, the air tastes like soil. You can cover your mouth with a scarf or balaclava, but after awhile the sand begins to overwhelm the fabric and you realize that the faint taste of Indiana farmfield lingers on your tongue.

As we are not here long, my group is in temporary housing that consists of groups of 8-10 person tents that resemble a desert tenement slum. Perhaps because they are old, or perhaps because they have been battered by winds and sand for a few years, the tents give the impression that they were erected during a British expedition sometime in the late 1800s. I know they are slightly more contemporary as they boast concrete floors, fluorescent lights and air conditioners (although we have not used them as the temperature is pleasant now in Kuwait).

The tents are stocked with bunks and lockers rumored to have been obtained from the hold of a charred delivery truck found burning on the "Highway of Death" shortly after the first Gulf War began: the bunks have varied frames and mattress sizes and most of our lockers are missing doors.

One of the most appealing features of this base is the food. Kellog, Brown and Root, now known as KBR Services and a subsidiary of Halliburton, provides our meals, and the variety and quality is very good. The reported daily price to the US taxpayer for an individual's meals is $71. Unfortunately, I find that I am only able to eat approximately $50 worth of food most days, thus preserving KBR's profit margin.

I wanted to take photographs of the dining facility, but was told such actions could somehow breach base security. Specifically, I wanted a shot of the dessert case. The sign overhanging that section reads "desert," but the offerings include fruit cheesecake, chocolate cheesecake, pies, tarts, cookies and brownies at every meal. There's also Baskin Robbins ice cream, ice cream sandwiches, and soft serve ice cream with nuts, whipped cream and fruit toppings available. No Nutty Buddies in the freezer, so Elvis would be upset, but otherwise anything you need frozen or sweet to keep you overweight and happy.

Army Training: Hurry Up and Wait

2008-03-04T07:57:00.000-08:00

Boredom and monotony bedevil the life of every enlisted soldier. So much of your existence consists of waiting for nothing to happen. Everyone jokes about the urgency to "hurry up and wait." Below is a typical daily itinerary for my last three weeks training with the Army at Fort Jackson, SC. You'll notice that most of the day calls for waiting. I'll employ the Naval euphemism: to standby.

05:15 Wake up and personal hygiene time
05:45 Gather by platoon for personnel and weapons count, then standby
05:50 Ensure complete platoon formation, then standby
06:00 Company formation for announcements
06:05 Breakfast
06:25 Platoon formation anticipating company formation, then standby
06:30 Company formation to announce schedule changes from thirty minutes prior
06:35 Break for first training exercise, then standby
06:45 Training schedule revision announced, instructions given to standby
06:55 Announcement that training schedule revision rescinded
07:00 Announcement that training exercise to begin soon, then standby
07:15 Announcement that training exercise to begin soon, then standby
07:25 Exercise instructor arrives
07:30 Projection equipment found to be malfunctioning, instructions to standby
07:40 Projection equipment repaired
07:45 Training exercise begins
08:30 Training exercise concludes
08:35 Bathroom and smoking break
08:45 Reconvene for second training exercise, then standby
08:50 Announcement given that presenter in route, standby
09:10 Second training session begins
10:00 Bathroom and smoking break
10:10 Reconvene to complete training exercise
10:20 Training exercise complete
10:25 Bathroom and smoking break
10:40 Reconvene for final morning training exercise, then standby
10:50 Announcement to standby for training schedule revision
11:00 Announcement to standby for training schedule revision
11:15 Bathroom and smoking break
11:30 Reconvene for final morning training exercise, then standby
11:40 Announcement to standby for revision to training schedule
12:00 Break for lunch
12:35 Platoon formation in anticipation of initial afternoon company formation, then standby
12:45 Company formation to announce no revisions to afternoon training schedule
12:50 Break for first afternoon training exercise
13:00 First afternoon training exercise begins
13:45 Bathroom and smoking break
14:00 First afternoon training exercise reconvenes
14:15 First afternoon training exercise concludes
14:20 Bathroom and smoking break
14:30 Reconvene for second afternoon training exercise, then standby
14:45 Second afternoon training exercise begins
14:50 Exercise interrupted, all personnel ordered to medical for screening
15:00 Formation at medical building for screening, then standby
15:15 Majority of personnel excused from medical without screening
15:20 Announcement to standby for further instructions for afternoon
15:30 Announcement to standby for further instructions for afternoon
15:45 Personnel excused for afternoon
15:55 Messenger to barracks to announce immediate formation
16:00 Company formation to announce revision to afternoon training schedule
16:05 Company dismissed for additional afternoon training exercise
16:15 Personnel convene for additional afternoon training exercise, then standby
16:25 Announcement that additional afternoon training exercise to begin soon, then standby
16:30 Announcement that additional afternoon training exercise to begin soon, then standby
16:45 Announcement that additional afternoon training exercise cancelled, then standby
16:50 Announcement to standby for further information
17:05 Personnel dismissed for the day

This typical itinerary helps to explain why so many military personnel smoke and drink.