BMJ No 7120 Volume 315
Personal view Saturday 29 November 1997
Ketamine and Kalashnikovs
Fridays are mine injury days. The local custom at the end of the week is to eat alfresco, but the picnics take place in one of the world's most heavily mined areas. One step too many off the marked paths and a young man lies asleep on the operating table while his father is ushered in to inspect the mutilated limb. The older man remains impassive at the grotesque sight - as head of the family he just wants to make sure the leg is beyond salvage before giving consent for amputation. All in all, it's a routine trauma list.
This is Kandahar, in the Taliban heartland of southern Afghanistan, and home for a three month mission working as an anaesthetist for the British Red Cross. The hospital is supported by the International Committee of the Red Cross, which has a mandate to provide humanitarian aid in areas of conflict. The emblem is displayed prominently at the entrance alongside two notices, one prohibiting weapons within the building, the other a reminder not to spit on the floor.
| The Taliban arose from refugee camps in neighbouring Pakistan and Iran,
and have swept north to control most of the country. Their imposition
of religious law - sharia - is brutally strict, and has been widely
reported in the world press. Music, television, sport, and other forms
of entertainment are all banned in pursuit of Islamic purity. After
almost 20 years of fighting, the Afghans retain a keen sense of humour
and a philosophical outlook on life. The acceptance that events are
subject to divine will - in sha' allah - is integral to their culture,
and acts as a robust coping mechanism for their ever changing fortunes.
How does Taliban rule affect work in the hospital? The first noticeable difference is the lack of female nurses. They are restricted to working behind locked doors on the women and children's wards, and must wear the all enclosing burqa in the presence of men. My attempts to identify them are based largely on variations in height and shoe style; a request for them to wear name badges is met by a chorus of giggles from behind the veils. In the operating theatre the anaesthetic nurses are all male, sporting beards and haircuts which must meet the approval of the authorities. During long cases they regale me with stories of their days in the mujahadeen, but seem equally fascinated with the more mundane descriptions of my life in England. |  | |
| A Taliban guard with his Kalasnikov at the entrance to the hospital. The cassette tape on the flag pole symbolises the ban on music |
Images of any living form are forbidden, but photographs of patients for "medical" purposes are usually tolerated. Flexible interpretation and a wide angle lens has stretched this classification to include many in perfect health. There is no shortage of suitable subjects. Gunshot wounds and shelling injuries account for most of the casualties. Having never witnessed surgery more dramatic than the removal of an air gun pellet, the destruction caused by a Kalashnikov is sobering. The patients become frequent visitors to theatre as they follow the well established sequence of wound debridement and delayed primary closure.
Other cases are a mixed bag, reflecting the problems of a poor rural community. Head injuries, snake bites, burns, and obstetric catastrophes all take their chances on the rudimentary intensive care unit, where mortality is high. Clinical skills are sharpened in the absence of sophisticated imaging and monitoring, but treatment is often on a best guess basis. "Remember, this is Afghanistan" - a phrase not granting a licence for sloppy practice, but a reminder that with limited resources some deaths will occur despite everyone's best efforts. Conventional medical ethics sometimes take second place to the rule of sharia. Women cannot consent to their own operations - in one case of massive obstetric haemorrhage we stood by impotently during the search for a male relative. Anxiety and frustration mounted until he was found in the bazaar and gave permission for the caesarean. Mother and baby both survived, but it had been a close call. Earlier intervention would have served her better but would have invited reprisals from the authorities; there is a population to treat, not just individuals.
Another day sees a gathering in the operating theatre corridor. Taliban officials are requesting surgical instruments and staff for an operation on a patient elsewhere who is "too sick to move." They are persistent, but leave empty handed. An hour later, two men are brought in, each having undergone punishment amputation of the right hand and left foot. Convicted of robbery earlier in the day, justice had been administered with a butcher's knife in the public stadium. Our ethical stance had not altered the eventual outcome, only worsened the conditions in which it was reached.
"You can't change the system, so go with the flow" - the advice that I received in my first week serves me well for the most part, but there are turbulent patches along the way.
It is difficult to summarise such experiences without being judgmental, yet all Red Cross activities, including this article, are guided by the fundamental principles of impartiality and neutrality. What messages do I have which avoid the sensitive issues inherent in a country at war?
Firstly, the security of the whole delegation relies on everyone bearing collective responsibility in terms of their personal and professional behaviour. It makes for true teamwork, not the paper exercises beloved in the new world of clinical directorates, and is a rewarding experience.
Secondly, the clinical value of working in such a different environment has matched a previous spell overseas in a recognised teaching hospital. Straying from the conventional path may not feature on everyone's ideal curriculum vitae, but if nothing else will provide a good talking point at dinner parties. A junior doctor's career should be shaped by the individual and not just be a vehicle for well meaning advisers to live their own lives by proxy.
Thirdly, time spent abroad is a rite of passage for many British trainees, but the unpredictable staffing requirements of relief organisations are not geared to the forward planning necessary to take time out of a Calman training programme. My advice - work in a department with an enlightened attitude to postgraduate training and persevere. You too may enjoy a unique adventure. In sha' allah.
James Rogers
senior registrar in anaesthesia,
Bristol
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