January 31, 2010 - Update from Kabul

Life has been busy, hence few blog entries. It was heartwarming to be home in Minnesota over the Christmas holidays, seeing and greeting many friends, colleagues and spending time with family. I was somewhat humbled by how many of you told me you followed this blog and looked forward to posts. Sorry the entries are somewhat few and far between. Rest assured I am safe, challenged and fascinated by the work I am doing.

Interesting challenges continue every few weeks in Kabul. We have had the usual many cases of “Kabul crud” which is a respiratory virus complicated by the dirty, smoke-filled air of Kabul. It causes a more prolonged cough along with an increase in sinus infections, asthma flare-ups and even occasional cases of pneumonia. More people arrive in Kabul daily, but not all arrive healthy. More of the one-year contract workers for the Department of State, USAID and the Department of Agriculture are recently retired folks in their 60s to early 70s. They have much-needed skills, but also have the ills many in that age group share – obesity, arthritis, high blood pressure, current or former heart disease, high blood pressure, and even some with diabetes. We work with them the best we can to cover their health care needs. This is not so difficult in Kabul where I have good assistants, a small lab in the health unit, a reference lab in the city, and basic x-rays available at an army base located in Kabul. Managing chronic health conditions in the Provincial Reconstruction Teams (PRTs) is much more difficult because there is no ready access to a lab, x-ray, or hospital. Some PRTs are staffed with physicians in a small MASH-like stabilization tent or Quonset hut. If an emergency arises, people from the PRTs must be helicopter-evacuated to one of 6 regional field hospitals run by various NATO countries. If there is a concurrent emergency need by soldiers for the same helicopters, the military personnel come first. Specific arrangements (Memoranda of Agreement, or MOA) must be executed with each hospital host country to allow USG civilian employees access to medical services.

When someone is seriously ill, I need to use the resources of the French-run military stabilization/evacuation hospital in Kabul. That was especially interesting when I had a man in his 50’s with chest pain and poor heart rhythms that needed to be stabilized and then evacuated to Germany for an angiogram. I was at the hospital, working along with French, Portuguese and German physicians to get him stabilized and ready for transport. It was fascinating to serve together with these talented physicians from other countries. It was even better that we all agreed on exactly what medications, tests, and treatments were needed. Fortunately, that patient did very well as he was eventually treated with a balloon angioplasty and stent to his main heart artery.

We must always be prepared for a medical crisis from fighting in the city. Although Kabul has been relatively safe and stable for many months, there have been several attacks and car bombings by Taliban fighters in recent weeks. I was recently speaking at a medical orientation for new arrivals, when nearby bombs exploded, one after another for an hour or so. That attack, put down successfully by the Afghan army and police, occurred about 1 mile from the embassy. It has caused us to redouble all the security arrangements. We do not travel outside of the embassy compound unless necessary for business or emergencies. So far, no embassy civilians have been hurt or killed in Kabul. But the coming months will remain dangerous. We continue with training and mass casualty drills to be ready for possible injuries in the future.

I recently had the chance to venture outside of Kabul to visit two of the four Regional Command Platforms that serve as headquarters for the USG civilians from many agencies that serve throughout the country in the local provinces. In mid-2008 there were fewer than 50 civilians working in the outlying areas; now there are over 300, with another 300 planned over the coming year. They serve at 64 different outposts. I visited Mazar-i-Sharif in the north and Kandahar in the south. In each command location a small group of civilians live and work among the thousands of army troops. They coordinate the activities of all the people working in the small PRTs and District Support Teams (DSTs). Living accommodations are austere, with barrack accommodations, shared bath facilities, mess hall eating and little opportunity for private space or private time. At the most remote posts, the DSTs, 1-3 American civilians are imbedded with 150-200 soldiers. They live in tents, use latrines, and clean up daily with what amounts to an oversized “Baby Wipe”. Nonetheless, the people I met were hard-working, optimistic and committed to making life better for the Afghan people and helping them develop local and regional government structures that serve the needs of the local population. That is their primary mission, as the military forces oust the Taliban, provide basic security for local villages and cities, and assist in fostering a sense of trust in the local people.

My travel to a small Canadian-run PRT was exciting. I hitched a ride with Canadian troops on a night-time military convoy in armored troop carriers equipped with night-vision cameras. We frequently had to stop while soldiers patrolled the ditches and nearby mud huts for any threats or signs of mines or IEDs along the road. Of course we all wore armored vests and helmets, huddled on our bench seats in a cramped posture for the 1 ½ hour journey. The night I traveled was lucky – the only moving things noted on the scanner were stray dogs and several camels in the yards of their owners! Not all convoys go so well. I now have a first-hand appreciation of the cautious apprehension that is a part of every convoy in a war zone.

The most heart-warming event in my stay in Afghanistan so far occurred while visiting the PRT on the northern outskirts of Kandahar city, where fighting has been fierce in the past two years. A local family brought their 2 year-old daughter to the tiny military health unit after she was scalded by spilled boiling tea down her entire torso. She had extensive burns, not adequately treated by a local physician. I was able to teach a young Canadian physician (just completed her training in the past year) to debride the burn wounds carefully, followed by special antibiotic application and dressings. It will likely take treatments 2-3 times a week for another month, but I think the beautiful girl, named Assima, will eventually heal the wounds. Her father was very appreciative. It is the type of diplomacy that works wonders in building trusting relationships.

Life is full of contrasts. 6 days after returning from the Kandahar province, I packed my bag to head off to Bangkok, Thailand for the annual medical conference sponsored by the Office of Medical Services….