The dead get priority

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

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

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

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

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

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

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.