Sonoma Medicine Magazine: Breathing
Volume 61, Number 2 - Spring 2010
Joseph Eichenseher, MD
She was a 24-year-old mother of a rambunctious toddler. Two years ago she noticed a painless bump on her own left knee. She tried to ignore the bump, but it grew larger and larger. After a year she could no longer walk or do household chores. Because she was living in a remote Afghan mountain village, she had no access to medical care. The mass kept growing, and she lost the ability to bend her leg.
Eventually the young mother’s impoverished family scraped enough money together to make the nine-hour truck ride into the capital, Kabul. The British orthopedic surgeon working with me at CURE International Hospital quickly biopsied her leg and determined that the mass was a rare Giant Cell tumor, benign and usually harmless, yet so advanced that her knee and leg couldn’t be saved.
The young mother was just one of hundreds of dramatically underserved patients whom I helped care for in Afghanistan. They presented a tragic parade of infectious disease (especially tuberculosis), war wounds, post-traumatic stress disorder, emphysema from wood stoves, birth trauma fistulas—an entire gamut of morbidity and mortality.
Why was I in Kabul? What would lead me to a land suffering from the scourge of 30 years of constant war? The average life expectancy of a person in Afghanistan is 45 years. One in every eight Afghan women dies in childbirth, and each has on average seven children. The median age in the country is 17.6 years (compared to 36.7 for the United States), and it has one of the worst literacy rates in the world (28%). What would draw a third-year family medicine resident to this corner of the planet?
For two separate months during our family practice training in Santa Rosa, we residents have the opportunity to travel and serve throughout the globe. My inspiring colleagues work on projects from Guatemala to Malawi to Southeast Asia. For me the decision to do medical work internationally was simple. As a child, I was fortunate enough to live for periods of time in Malaysia and Indonesia, and as a young adult I worked with AIDS patients in Uganda, with Mayan villagers in Guatemala, and with diabetics in a Palestinian refugee camp. My experiences teach me that all 6 billion people on this planet are fundamentally interconnected. The health and well-being of one group is linked to all others—from infectious disease to environmental to emotional concerns. The survival and well-being of our grandchildren, great-grandchildren, and all future generations depend on each other.
I learned of the opportunity in Kabul from a former resident, Dr. Radha Lewis. A few years ago she worked with an Afghan family medicine residency program, run by an American non-governmental organization, which was training (and learning from) a new generation of Afghan physicians. She encouraged us to likewise serve, and I jumped at the opportunity. Afghanistan was an ideal place to put my beliefs into action, working to empower health care workers and rebuild infrastructure in a vastly underserved, war-torn country.
Afghanistan was once a tourist beacon, with its harmoniously diverse and hospitable people dwelling in the scenic Hindu Kush Mountains. Yet in 1979 Afghanistan was thrust into the geopolitics of the Cold War. A Soviet invasion led to an American-funded resistance in the 1980s, resulting in 1 million Afghan deaths and 6 million refugees fleeing the country. Billions of rubles and dollars were poured into Afghanistan in the form of guns and explosives. When the Soviets left in 1989, the world turned its back on Afghanistan, and heavily armed groups dragged the already ravaged country into a quagmire of civil war and lawlessness. During this period 90% of the buildings in Kabul were destroyed.
Out of this chaos the religiously extreme and draconian Taliban came to power, restoring order at the price of freedom, especially for women, who were not even allowed to attend school. After 9/11 the Americans refocused on Afghanistan, overthrowing the Taliban and ushering in the current eight and a half years of smoldering conflict. As the international community races to reestablish education, health care, justice, and a functioning economy in the country, a Taliban insurgency rebounds and strengthens. And as time goes on more and more of the fiercely independent Afghans resent the presence of foreign troops, the deteriorating security, the increasing civilian casualties and the corrupt, ineffective government.
(top) The ruins of Darulaman Palace in Kabul.
(bottom) Dr. Eichenseher with Afghan resident physicians.
Not without hesitation, I descended into this maelstrom last October and November. Because of security concerns, I considered not going up until the last days before I left. The thought of traveling to a war-torn country by myself certainly gave me reason to pause. Yet in the end I trusted my gut and took five separate flights before landing in Kabul.
I was picked up by one of the CURE International Afghan staff members at the Kabul International Airport and taken to a guest house in the city. The next day I was working with the CURE team, which has operated in Kabul since 2005 at the request of the Afghan Ministry of Health. Supported by donations and equipped with basic medications and equipment, CURE runs a 100-bed hospital and a small outpatient clinic. For staffing, CURE hosts international surgical and primary care personnel on a rotating basis. As part of its agreement with the government of Afghanistan, CURE also trains up to six Afghan physicians per year, funding permitting, in the three-year manner of American family doctors.
The residents’ training is designed to meet the complex and comprehensive needs of rural Afghan communities, including basic surgeries like appendectomies. I worked with these residents, and I was excited at the chance to be involved in such an empowering, sustainable and rejuvenating program. I found my role similar to my senior resident position in Santa Rosa: supervising residents, working with attendings, seeing patients, taking overnight call, and working in both inpatient and outpatient settings.
I learned from my Afghan colleagues about the intense infections and war-induced psychological pathology that I had only read about in medical texts: a 13-year-old with brucellosis; a burka-clad war-widowed mother of 14 children battling depression, anxiety and PTSD; a 5-year-old girl with abdominal TB … . Lacking sufficient manpower and specialists, such as a cardiothoracic surgeon for our patient with severe aortic valve stenosis, we served a small fraction of the medical need, turning away dozens of patients each day due to lack of providers. We had to advise some patients to seek care in the better-equipped hospitals in Pakistan, Iran and India, even though many had already traveled several days and spent all their money to get to us.
Although my movements outside the hospital and living quarters were restricted, I felt safe. Surrounded by the snow-capped peaks of the Hindu Kush, Kabul is a bustling city of 4 million, an eclectic mix of various ethnic groups and refugees trying to eke out a living in the ruins and new construction that define the city. Our hospital had a security team that worked with and advised us, and I quickly learned how to avoid military convoys and potentially volatile situations. Thankfully we were located far from the heavily fortified, violence-plagued international district downtown. But it was still a surreal day-to-day existence, as Kabul is a garden of razor wire and countless automatic weapons. I carried a cell phone at all times in case there was need for an emergency evacuation. Yet I worked with my Afghan colleagues confidently, knowing that even the Taliban hadn’t targeted health care workers in this drawn-out conflict.
(top) Front of CURE Hospital. (bottom) Armed guard at hospital entry.
As I struggled and served alongside the Afghan residents, I learned more of their inspiring stories. All had been refugees at some point during their youth, mostly in Pakistan. Throughout their entire lives, they had only known war. While in medical school, Esmatullah had been severely beaten by the Taliban for not providing them with guns. Wasi came from an uneducated family but managed to get through medical school; now he moonlighted as a Dari language teacher to Korean doctors to make ends meet. Janat Gul had a resilient smile and would find ways to joke and lift our spirits when the weight of patient suffering was palpable. Burhan simply dreamed of one day practicing medicine in a peaceful and stable place.
As we shared kebabs in the call room, I learned that most of the residents were in arranged marriages and had met their spouses for the first time on their wedding days. They were intrigued by the concept of dating. We joked and mourned together, bearing witness for our patients as we shared thoughts and insights from our divergent medical training and life experiences.
They were tired of war. They much appreciated the civilian efforts of the international community, yet felt that more guns and soldiers would only cause more suffering and further empower the corrupt and violent elements of Afghan society. They had plans for becoming refugees again if conflict were to re-engulf Kabul. I tried to put myself in their shoes …
In the end, after a grueling and emotionally challenging month, I returned to Santa Rosa feeling blessed that I could so easily leave the guns, instability and chaos of Afghanistan, yet also torn by the fact that my new colleagues and friends could not. I was inspired by their daily courage, and honored by their amazing hospitality toward me. I can only hope to return the favor some day.
On one of my last days in Kabul, I saw the young mother after her amputation. She was smiling and glowing at her new ability to walk with crutches, reflecting the tenacious spirit of optimism that underscores the entire country. Afghans have a resilient hope that even after 30 years of gruesome war, peace will be found, and that a return to the halcyon pre-conflict days will usher in a new era of prosperity for their beautiful land. During my work in Kabul, I too was overcome with this infectious hope for Afghanistan’s well-earned peace and future stability.
Yet there is still much work to be done …
To volunteer or donate to the residency in Kabul, contact CURE International at www.helpcurenow.org.
Dr. Eichenseher, a senior resident at the Santa Rosa Family Medicine Residency, recently traveled to Afghanistan.